Choosing the right partner in a merger or an affiliation is not a process that is guaranteed to work out the first time. For one group of physicians in Seattle, hooking up with US Oncology seemed like a good idea at first, until circumstances changed and the deal no longer was a benefit for any of the partners. Jeffrey Ward, MD, a specialist in hematology/ oncology and a member of ASCO’s government relations committee, said that going back to complete independence in the Seattle market would not have been a good move, as rising costs would have overtaken the physicians’ ability to pay themselves.

A much more satisfying solution was found in a merger with what is now the Swedish Cancer Institute. Ward and his partners severed their ties with US Oncology, and after a period of fine-tuning and special arrangements to make the partnership a success, the deal began to mature into the more fruitful large-institution practice that Ward had hoped for, providing opportunities for career development along new lines, and a chance to practice higher level oncology with more sophisticated resources.

What follows is a question and answer interview with Ward about the transition from life as an independent practitioner and the trial and error process of finding a new business arrangement, leading to the eventual absorption by Swedish.

: Describe the early years that led up to the merger.

: I entered private practice in 1993 and was in a small group with two other physicians for a few years, at which time we merged with another private practice group down the road, becoming a group of seven and then quickly eight physicians; at the same time, we became a US Oncology national practice. We were with US Oncology for 15 years. We still owned and ran the practice and they were a consultant, so from our vantage point, it felt very much like private practice except we shared part of our income with our consultant.

It reached a point where two things became clear to us. One was that our practice and US Oncology no longer shared the same incentives. We were a medical oncology-only practice. We had not grown into the prototypical US Oncology model of one-stop shopping cancer care with imaging, radiation oncology, gynecologic and maybe surgical oncology. That’s what works for them: a midsize metropolitan community in which you can have a large enough presence that you cannot be ignored by insurers. The Seattle market, for a variety of reasons, including cost of property as well as the fact that the hospitals were well entrenched, was never going to work with that kind of model. I think the other thing is we probably didn’t have the right personalities in place to create the cohesion among the medical oncology community that would have allowed for that either.

First off, there was the Medicare Modernization Act, which certainly changed the way chemotherapy was paid for by Medicare. Initially commercial insurers kind of looked and watched that. But over time, they slowly all changed to Average Sales Price (ASP) -based reimbursement for chemotherapy. And then in tight times and in trying to lower cost, they just kept ratcheting down little by little what they were going to pay for reimbursement and became much tighter in preauthorization and things that increased your overhead, until we reached a point where we could see the trajectory and said if we continue in our current model, we won’t be in practice in five more years.

	What was US Oncology’s role in your arrangement?

	What was your thinking process in seeking an exit?

	What were your options for setting off differently?

	Did you go in fully understanding what was involved or did you meet with some factors that perhaps were a surprise to you?

US Oncology initially wasn’t too happy about that. They had a long-term contract with us, but I think they could see the writing on the wall, as well. It doesn’t matter how big their percentage was—100% of zero would still be zero. So, we began looking for possible soft landing spots, and we had really three hospital systems at the time that we could look at and that we talked to in making a decision&mdash;because just leaving US Oncology wasn’t going to change anything. That probably would have made things worse.

They had essentially rented the practice for 30 years, and we paid them a percentage; we paid them a fee that was based on what money they had put into our practice to begin with. And then we paid a percentage of our profits. So, when we first joined US Oncology, we were able to make that and more back simply by the fact that they were able to buy drugs at a whole lot cheaper price than we could on our own. But, with the Medicare Modernization Act, a very interesting thing began to happen to prices: any time a drug company would give US Oncology a deal, either their ASP would drop or they’d have to compensate for it by raising the prices to somebody else. And so what was initially about a 10% improvement on our margin, over time dropped to about maybe 2% better than you would get on the open market. And when you are paying them a hefty percent of your profits, they become a weight on your practice instead of a help.

We needed a soft landing place that (1) would be willing to help us get out of our contract with US Oncology and (2) that we could live with and work with as oncologists, and still feel comfortable with the care that we gave and with our new bosses. And that was harder for some docs than for others.

We had three potential suitors. We had Providence Health & Services that was north of us, and the University of Washington, and the Swedish system, and we talked to all of them. And it became clear to us fairly early on that philosophically and as far as just individual personalities go, we were much more comfortable with the Swedish Cancer Institute as a potential partner than our other options. And I think that’s the most critical thing for somebody who’s thinking about doing this: you have to have a partner, whether it’s a hospital or otherwise, that you can trust, that you feel comfortable is in alignment with the way you want to practice medicine and your vision. Swedish had, for a long time, been a big downtown hospital, but they had come to the realization that just as we weren’t going to be able to continue to exist as a community stand-alone medical practice, that a big downtown hospital wasn’t the future of medicine either and that they needed a large regional presence and that they needed to expand their footprint.

One of the things we didn’t recognize until after we really got into discussions was that for a hospital to make this work for them, they need to have you practicing in a hospital facility. And so though we were on the hospital’s campus, we were not in office space that was hospital-compliant and that would allow the hospital to bill as a hospital. That meant they had to build a new cancer center, and that took a few years for a variety of reasons: environmental impact of impervious surfaces, parking easements, permit bureaucracy— that kind of stuff.

	You had hoped to be doing more sophisticated work with US Oncology, but were unable to. Did that become possible once you joined Swedish?

So, we actually became a foundation for several years. We operated the same way we always had as if we were in private practice, but Swedish funded the foundation. That allowed us, in a protected way, to watch and see what would have happened if we had stayed in private practice for four more years; and the answer was that by the end of those four years we would have been working for nothing in order to pay the salaries of the rest of the folks in the clinic. And so it was a big eye-opener for us.

We now have been in the new cancer center for two years. We’re part of a larger group. Swedish has actually since then merged with Providence, and the merging of the Swedish and Providence cultures has, I think, been a bigger stretch than our entry into Swedish. So, I think that when you give up control you have to understand that there may be mergers and other changes, and they may have impact on you, and that may, at times, make you somewhat uncomfortable. But there is no way to avoid the turmoil in healthcare by staying in private practice either. You still have to make sure that the people that you immediately work with are people you can trust to be transparent, open, and fair with you, and that’s been our case.

Swedish already had radiation oncology on our campus, so we’ve now been able to integrate into a system that has all of those things that we had never had. So the Swedish Cancer Institute is actually an affiliate of practices, some employed and some actually in private practice, but the system includes surgical oncology, interventional oncology, and radiation oncology, plus a large clinical trials program that gives us more opportunities than we had within US Oncology. Swedish also has a philosophy that they will take care of anybody who walks in the door. That’s just part of their mission. Same for the Providence system.

So, one of the things that’s really different is when a patient comes to see me, I don’t have to worry about how caring for them will impact the bottom line. I don’t have to send patients with no insurance, Medicare without a supplement, or Medicaid to the hospital to avoid losing money. I don’t have to practice two different kinds of medicine, one for those who have insurance and one for those who don’t, because I’m now part of a hospital with charity care as a core mission. I’m sure it’s not that way with every hospital, but it is with the one that we chose to join.

Articles

For one group of physicians
in Seattle, hooking up with US Oncology
seemed like a good idea at first, until circumstances
changed and the deal no longer was a benefit for any
of the partners.

Second Partnership Was the Charm for Seattle Oncology Practice

: Could you highlight some of the important findings of your study?

	Were there any results that stood out and were completely unexpected?

	Could early interventions in the care pathway help? Who could possibly lead the intervention?

A new study conducted by researchers at Kaiser Permanente has found that a considerable number of working-age adults who survive cancer and its toxic treatments, end up with substantial medical debts or declare bankruptcy. 

asked Matthew Banegas, PhD, MPH, a health services researcher at the Kaiser Permanente Center for Health Research, and lead author on the study, to provide additional insight on the study results and any follow-up studies that may be conducted.

: We found that working-age cancer survivors— people 18 to 64 years old&mdash;often went into debt to pay for their cancer treatment. In fact about one-third incurred debt or had to borrow money, and one-tenth of those people who incurred debt or had to borrow money reported filing for bankruptcy. While there is data out there on financial hardship facing cancer survivors, this is one of the largest studies to focus on workingage cancer survivors, and it includes people from all 50 states.

There is a growing body of evidence that indicates financial hardship from cancer is common. However, the finding that surprised me most was the magnitude of the debt. We found that among those working-age cancer survivors who incurred debt or had to borrow money, more than 55% had debt amounts of $10,000 dollars or more.

If people can identify sources of financial assistance and learn more information about the costs of care shortly after they are diagnosed, we may be able to prevent some occurrences of financial hardship. Too often, patients don’t find out about the costs of cancer care until after their treatment.

Individuals diagnosed with cancer should ask about financial counselors or social workers at their local health care facility. They can also reach out to foundations like Livestrong or the American Cancer Society to find out whether other local resources are available.

	Some of the newer oncology agents are quite expensive, although they have substantially improved outcomes and survival. Since your study used data from years prior to these newer agents, how relevant is this information in the current day?

	Are you conducting any follow-up studies?

	What are key lessons to be derived by cancer patients and treating physicians from these results?

We also need more studies that follow cancer survivors over time to see how the costs of cancer care affect their long-term financial situation, employment, and insurance status—from the time of cancer diagnosis through treatment and beyond. This will allow us to develop financial assistance interventions tailored to the patients who need it most and at the time when it is most helpful.

Our study findings are very relevant to this discussion. The costs of newer cancer agents have been rising over the past decade. Since, the study data comes from the 2012 Livestrong survey, many of the cancer survivors who participated may have been treated with, or considered, one of these novel costly agents. The important thing is that patients should be able to weigh the risks of the treatment along with the benefits when making their decisions. Many of the newly approved cancer agents have been shown to extend life by a few months, not years, in clinical trials. Accordingly, patients should have information available that explains the survival and quality-of-life benefits, as well as the potential toxicities, and costs of these agents. It is important for patients to discuss this information with their families, or significant others, and their healthcare team.

Yes, we are currently working on a follow-up study to understand whether experiencing financial hardship related to cancer has an impact on access and use of medical care. Additionally, we are looking into the types of sacrifices made by individuals in financial hardship, in hopes of describing how the financial impact of cancer affects patients’ lives.

Cancer treatment costs are growing tremendously and patients are expected to pay some of these costs, even when they are insured. Working-age patients face unique challenges because they may have to take time off from work, use extended time or extended leave, all of which could impact their insurance coverage and their pay. Also, they often don’t have the savings that retirees do. This study shows that it is important for patients to be aware of the costs and to discuss them with their healthcare providers, so as to prevent financial hardship from occurring. Ultimately, we hope that our work leads to well-informed patients and encourages them to gather information so that they can make decisions that are in line with their personal values and preferences.

Surabhi Dangi-Garimella, PhD, is a writer and editor for the American Journal of Managed Care, Evidence- Based Oncology. Read more at 

Matthew Banegas, PhD, MPH, discusses a recent study that found that a considerable number of working-age adults who
survive cancer and its toxic treatments, end up with substantial
medical debts or declare bankruptcy.

Bankruptcy in Cancer Survivors

Newer, more stringent USP 800 regulations on cleanrooms are a couple of years off, thanks to a postponement of implementation, but they’re still a worry for independent oncology practices, whose in-house pharmacy staff may sit up nights wondering about the stability of their drug revenues.

The newer regulations, set to debut in 2018, could require separate cleanrooms and storage, an appointed supervisor, special garb, and annual competency training. Like many other tasks and requirements at oncology practices, these things are not subsidized by payment from the Centers for Medicare & Medicaid Services or any other plan. “I spend thousands of dollars a year to have my cleanrooms and hoods certified and maintained,” says Steve D’Amato, executive director of New England Cancer Specialists, in Scarborough, Maine. “That’s an unreimbursed service, but it’s the cost of doing business.”

New England Cancer Specialists is the last independent oncology practice in Maine, and the challenges of drug procurement and dispensing are among their chief concerns. The Northeastern practice has four locations in Maine and a satellite facility in New Hampshire. Like all independents, they must grapple with increasingly aggressive policies among payers, pharmacy benefit managers, and pharma companies. Competition from specialty pharma is ever-present.

For the New England group as well as for Florida Cancer Specialists & Research Institute, the nation’s largest independent oncology practice, the battlefield strategy is the value mantra: the constant broadcast of the message to payers and pharma that independents can deliver lower cost and greater efficiency in handling and dispensing of drugs.

“What I tell payers is, ‘Look, you’re trying to extract savings out of small, community oncology practices and all you’re doing is driving them into the arms of hospital systems, where you’re going to get charged three times as much when they go into that site of care,’” says Ray Bailey, RPh, the pharmacy director for Florida Cancer Specialists & Research Institute. “That’s the most compelling argument to the payers. You need to work with and partner with community oncology, because that’s your most cost-effective site of care. And I think they’re understanding that, or at least my experience with payers is they’re understanding that.”

Of course, Florida Cancer Specialists & Research Institute has the advantage of size. Established in 1984, it now encompasses 90 practice locations and 190 physicians throughout the panhandle state. Such an extensive network makes Florida Cancer Specialists & Research Institute a distribution channel whose interests cannot be treated lightly. It has a well-organized in-house pharmacy operation, says Bailey. Many independent practices that have joined Florida Cancer Specialists & Research Institute over the years did not have orals included in their dispensaries, and that changed when they became part of the larger system, Bailey says. “Thirty-five percent of our business is orals now, and it’s going up and could very well be 50% in the next five years,” he says.

Things could change for the worse if Congress is persuaded by the pharmacy benefits manager (PBM) industry to change the “any willing provider” language currently in the Medicare Modernization Act covering Medicare Part D (pharmacy benefit). Right now, patients have a choice of providers including the practice pharmacy or dispensary. PBMs want to change these laws in order to restrict patient access and choice. For most practice pharmacies, as much as 50% of their business is at stake in this struggle, Bailey says 

Better Systems Needed to Demonstrate Value

Getting left out of the discussion on drug distribution also is troubling. “It’s the commercial lines of business where the pharmacy benefit managers have been very effective in getting to large employer groups and regional carriers in selling their pharmacy benefit plans to them. We don’t even get to come to the table to talk about pricing and benefit. It’s a totally unfair way of doing business, and our patients don’t get the care our model can provide them,” he says.

To break through these barriers, it is increasingly necessary to demonstrate the value independent oncology practices can deliver, Bailey and D’Amato say. Drugs have to be used judiciously, and costs have to be trimmed wherever possible, and this has to be demonstrated by implementing quality control systems and measures of performance that provide the proof. “There’s both risksaving and there’s reward if the practice is able to show these savings,” says Bailey. “The challenge to us is going to be to beef up our care management and information technology infrastructure, so that we can collect this type of data.”

Florida Cancer Specialists & Research Institute has partnered with large payers on these issues and is able to fill in-house oral chemotherapy prescriptions for its patients, Bailey says. “Our pharmacy is better able to manage these patients at the practice level. We have access to electronic medical records and can collaborate in real time with the doctors and nurses in the clinics to manage side effects and ensure compliance with prescribed regimens. Other payers have seen the value of our model, and we are developing pilots to show improved patient outcomes when these patients are managed inside the practice.”

Even for a practice the size of Florida Cancer Specialists & Research Institute, the rise of specialty pharmacy represents a constant threat to the continued momentum of in-house drug administration. The way D’Amato sees it, when it comes to drug dispensing, the smaller, independent practice has an advantage in delivering value care because it has access to patient records and can do full-range care and follow-up. Even so, it is not easy to cut specialty pharma out of the picture. “Some of our payers will allow us to do a first fill and then it goes off to specialty,” says D’Amato. “We try to do as many (prescription fills) as possible for our patients because of the convenience and the continuity of care and follow-up that our patients receive.”

Figure 1: Managed Care Contracts Require Oncologists to Obtain Drugs Through Specialty Pharmacy

Source: The 2015 Genentech Oncology Trend Report.

For the New England group, much of the pharmacy management strategy has revolved around simply holding regular meetings wherein issues that arise can be quickly identified and addressed before they become insurmountable problems. D’Amato notes the dangers that extremely costly orals can present when they are dispensed but not reimbursed. “If you don’t have a strong inventory management program and a strong billing program that tracks all of this, practices can get into trouble very quickly today with the costs of these agents. Any waste, any misuse, any lack of tracking of reimbursement could get you into trouble very quickly.”

Both the Florida Cancer Specialists & Research Institute and New England practices strongly endorse split-fill programs that allow the issuance of partial prescriptions so that patient adherence, efficacy, and toxicity can be tested before full prescriptions are ordered and much larger sums of money are invested—and potentially wasted&mdash;on expensive drugs.

Specialty pharma has hopped on the trend. According to last year’s Genentech Oncology Trend Report, “Split-fill programs to reduce waste saw a sharp rise from 68.2% of [specialty pharmacies] in 2013 to 86.7% in 2014” 

.The waste potential in full-prescription issuance goes up exponentially through the practices of white-bagging— having drugs delivered to the practice from specialty pharma&mdash;and brown-bagging&mdash;allowing the patient to pick up cancer drugs at the pharmacy for administration by the practice, D’Amato and Bailey say. Bailey describes large quantities of unusable drugs found at practices that formerly did white-bagging and were stopped from engaging in that activity when they merged with Florida Cancer Specialists & Research Institute. “It’s amazing the amount of inventory they’d set aside for patients whose doses changed, whose regimens changed. They had labeled vials and packs of very expensive drugs for patients that were not used. Once they are dispensed they cannot, by law, be taken back. There’s tons of waste there.”

D’Amato agrees: “That’s where you don’t want specialty pharmacy sending a 90-day supply out of the gate to the patient and then have the dose changed a week later and have the whole supply thrown out, and that happens all the time across the country.”

Figure 2: Most Common Duration of a Split-Fill Option

Both independents say they eschew these practices, though an increase in white-bagging and brown-bagging was forecast by specialty pharmacies surveyed for the Genentech report, which states, “more than half of the surveyed [specialty pharmacies] forecast an increase in the share of prescriptions for cancer drugs delivered to patients’ homes for selfadministration (70.0%) and delivered directly to oncology practices (53.4%) in 2015.”

D’Amato notes that the cost to practices of external prescription management comes in another form as well. If a patient walks into the practice carrying his own medication or if the medication is delivered from a specialty pharmacy, the practice reaps no reward for doing the job of administration, though it assumes all of the risk for the way the drug may have been stored or handled before it arrived at the practice. “I’m the one that’s taking the drug and reconstituting it—my pharmacy staff is dealing with it, my nurses are administering it&mdash;but I’m not generating anything or gaining anything for that task, so why would I do that?” D’Amato says. “If an insurer tried to push back, I’d say, ‘Well, your patient needs to go to a different clinic,’ or ‘You need to sign a waiver to accept full liability for this agent that you’re bringing to me.’ That’s how I might handle it, but it’s a non-issue for us.”Improved patient compliance and prevention of waste are part of the value proposition for Florida Cancer Specialists & Research Institute. The group’s pharmacy and practice have collaborated on the development of specific oral adherence care plans drug by drug. “We follow up weekly with patients at the start of care to help them manage side effects,” Bailey says. “We stress the importance of taking the medication as prescribed. Having access to the EMR, we see labs in real-time. That, along with adverse side effects a patient may report, puts us in a unique position to alert our clinics if a dose reduction or drug holiday may be necessary. The pharmacy is routinely able to prevent unnecessary refills of very expensive oral chemotherapy.”

Delayed drug payment ties up a huge amount of capital and continues to be an administration headache for D’Amato. He believes that the development of pathways care may hold the solution for improving payment schedules, and the New England group is doing pilots with payers that are designed to cut down on the logjam created by prior authorization requirements.

For Florida Cancer Specialists & Research Institute, the initiative to strengthen the in-house pharmacy program is moving on several other fronts. A Patient Assistance Team works full time to find financial assistance to break down that barrier to patient access to drugs. “We get everyone access that they can afford, and most of these plans are very liberal when it comes to qualifications. Very rarely do we get a patient who doesn’t qualify for some type of assistance,” says Bailey. Strengthening its value proposition, Florida Cancer Specialists & Research Institute is building a care management team that will be in constant contact with patients from arrival to palliative care or through survivorship,” Bailey says. “We’re going to have a team that’s going to help patients along the way, and that’s what the Oncology Care Model is going to be all about.” In addition, Florida Cancer Specialists & Research Institute continues to pressure pharma to gain drug access. “We work very closely with them prior to the launch of their drugs, making sure that they understand our model. Pharma companies are defining different distribution models where they look toward single source pharmacy distribution and cut us out of access to limited distribution drugs, and that is something that we constantly fight.”

1. Genentech. The 2015 Genentech oncology trend report: perspectives from managed care, specialty pharmacies, oncologists, practice managers, and employers. Academy of Managed Care Pharmacy website. www.amcp.org/WorkArea/DownloadAsset.aspx?id=20229. Published 2015. Accessed January 26, 2016.

Newer, more stringent USP 800 regulations on cleanrooms are a couple of years off, thanks to a postponement of implementation, but they're still a worry for independent oncology practices, whose in-house pharmacy staff may sit up nights wondering about the stability of their drug revenues.

In-House Pharma Feeling the Pressure From Drug Industry Competition

When considering a merger with a larger institution or group of practices, the pitfalls are many for oncology practices. However, finding the right partner can lead to a much higher level of practice for physicians, as well as broader responsibilities that add fulfillment to one’s career, physicians and consultants told 

Those who have been through affiliations and mergers, or counseled them, said the best advice is to do your homework and thoroughly scope out the institution you are thinking of joining in order to make sure that the fit will be right for you and your staff. All of the details need to be worked out in advance so that nothing is hidden that might constitute a deal-breaker.

“In general, it is easier culturally when practices join practices, because they’re at least joining together with physicians who understand what life is like and what one’s priorities might be,” said Teri Guidi, president of Oncology Management Consulting Group. “Joining a hospital can be very different. Hospitals have all of their rules and regulations, and they have their personnel policies, so physicians joining hospitals do face a much greater chance of having those cultural lifestyle differences. We’ve seen practices that were acquired by hospitals who agreed to hire a practice’s entire staff and then the physicians learn that they don’t have the right or power to just fire a nurse. They have to go through all of the HR policies and procedures,” she said.

In its report last year on the state of cancer care in America, ASCO indicated that among nearly 1000 US practices surveyed in 2014, one-quarter of communitybased practices said they would likely pursue hospital affiliation over the following 12 months. There are many reasons why practices working independently would seek the embrace of a larger institution, said Cary Presant, MD, past president of the Association of Community Cancer Centers and a practicing hematologist and medical oncologist with City of Hope Medical Group in the greater Los Angeles region. The costs of maintaining a practice with adequate support have risen, compliance requirements are stiffer, there is greater demand for managed care and cost savings, and many oncologists are getting older and finding it harder to interest younger physicians in buying them out, Presant added. “They don’t want to pay a large amount of dollars for a practice that is more challenging today than it was 20 years ago, and so these older physicians are guiding practices very often to being taken over by hospitals.”

With hospitals anxious to extend their territories, having realized the advantage of satellite offices over centralized facilities, the mutual attraction is strong. Despite this, the cultural and administrative fit can feel like an itchy sweater, Presant said. In his position at City of Hope, Presant has seen many independent practices added to the system as the network of owned and affiliated practices has grown. The goal has been to leverage size in order to practice the most advanced oncology and to achieve City of Hope’s mission to extend better care into urban southern California.

	Salary May Be Low, But There Are Other Compensations

Larger institutions tend to have better developed clinical-trials programs that can actually be important revenue generators when they are well managed; for the physicians who join from outlying practices, participation in such activities can supply the feeling that “you’re really keeping up with where oncology is moving in these very tumultuous and exciting years,” Presant said. The alternative may be to continue to practice good, “standard” care in many of the oncologic disciplines in an independent community practice; however, the trade-off is that your program may not have the support necessary to offer the really advanced techniques and opportunities for specialization that, in addition to career advancement, can lead to higher volumes of patients and better overall outcomes, Presant said.

Those are some of the benefits that serve to lure physicians who want to improve their oncologic game. On the pay side, as well, it can get complicated, particularly when you throw in all of the compensations that do not strictly amount to salary. These include payments for the acquisition of the independent practice, pay for special duties that are assumed when a physician joins a hospital, and bonuses for meeting targets for attracting and seeing patients. “In some physician practices, their pay goes down, but they’ve been compensated by having an acquisition fee, and in some cases, their pay has gone up because they have received income for running parts of the program. Generally speaking, the benefits from institutional affiliation usually are pretty good with retirement,” Presant said.

Another big advantage of joining a hospital system is that suddenly you do not have to worry about whether the institution is going to survive; it’s almost a given that the institution is going to outlast you. One problem that does arise, however, is when you discover that being a cog in an immense system means that you are replaceable, physicians interviewed for this article said. Such a liability, combined with the other compromises that have to be made when you join a much larger system, can chafe at the egos and personal ambitions of independent-minded physicians.

“You’re going from really having total control over your own practice to being one of a group that is an employee of a larger practice. And so you lose a lot of control over what you do day-to-day. You gain a lot in terms of the kind of camaraderie and the kind of confidence you have in the system that you’re within and the type of compliance with national guidelines, type of compliance with the actual requirements of practice. Those things are taken out of your hands, and the institution takes care of all those details,” Presant said. “This has been very, very good for some people who have been overwhelmed by the amount of businessrelated activities and administrative activities they have to do in their practice. It’s been very bad for others who have liked being in control and suddenly they’re not in control anymore,” he added.

	Hospitals May Tap More Than Just Your Doctoring Skills

Jeffery Ward, MD, a hematology oncologist and a member of ASCO’s Government Relations Committee, said that on the upside, there are opportunities to participate in hospital initiatives if you are willing to leave certain aspects of your former practice responsibilities behind. For him, this has translated into an opportunity to bring a Quality Oncology Practice Initiative to the Swedish Cancer Institute, which was something the hospital wanted him to do based on his accomplishments as an independent practitioner.

“My impression is that they have recognized that we bring certain skills that we gained in private practice, and as much as the bigger Swedish (Swedish Medical Center) will allow them to do, the Swedish Cancer Institute is utilizing those skills and recognizing them, and that feels good,” Ward said. “One of the things that Swedish has done that we could never have done on our own is develop a personalized medicine research program, and they have signed an agreement with Systems for Improved Access to Pharmaceuticals and Services and are going to begin collecting big data and doing some things that really are exciting.” This is something Ward said he enjoys doing more than, say, the administrative task of interviewing nursing candidates. “I can now let somebody else run a business and I can build a cancer program.”

Physicians find that resources can be more plentiful at larger institutions, such as the availability of palliative care physicians and social workers, specialists whom their own smaller practices couldn’t afford to hire. But even with a bigger tool set and more elbow room to practice advanced oncology, a lot has to be said for the importance of hammering out the details and finding a partnership deal whose attractiveness is more than an illusion. In the end, it may turn out that remaining an independent is the best decision after all, those interviewed said.

“I think for every success story, there’s probably going to be a horror story, and some of that will relate to physicians who chose the wrong partners. Some of it will relate to people who were never suited to be in a hospital-based practice in the first place, and some of it will be because things changed once they got there,” Ward said, acknowledging that his group lucked out in being able to partner so successfully with Swedish.

Many things at a larger operation are liable to be different, and “people have to be prepared when they are considering doing this type of a transition for the very dramatic changes in culture and how it will affect them in their professional lives, and how it will affect them in their personal lives as well,” Presant said. Even burnout, a rising factor in job dissatisfaction among independent oncologists, can be a problem at hospital institutions, he said. There is no shortage of meetings at larger health care facilities, those interviewed pointed out. In addition, physicians may have to learn entirely different record keeping systems, despite the advantages of whatever they have become used to at their community practices. “Hospitals have a very large and complicated portfolio of IT systems, and they’re not generally very accepting of just bringing another system in,” Guidi said.

Even when physicians decide they want to join a network of independent practices, they may find that it becomes necessary over time for that larger group to begin implementing policies and procedures that are similar to those in force at hospital systems, which means that a certain measure of independence begins to erode, Guidi said. She cited the example of Regional Cancer Care Associates (RCCA), which has roughly 30 practices and has begun to extend its reach from New Jersey into other states on the East Coast. “Physicians, when they first started, joined for economies of scale and some negotiating power with payers, but the practices were pretty much allowed to remain independent and operate on their own. So, a doctor who was used to saying, ‘I want the walls to be painted in purple today’ could do that. That is changing in RCCA a bit and in some of the larger groups.” They’re looking to make things consistent across all of their platforms so that revenues are maximized and expenses brought under control, Guidi said. “They’re also looking at compliance-type issues. If there’s an audit at one of their sites and there’s an issue, the larger group may be held accountable.” It’s also important for them to be able to demonstrate to the payers they’re negotiating with, using group strength, that they have their costs under control from practice to practice, Guidi said.

For those who discover that their merger agreement or partnership arrangement has wound up at the closed portion of a dead-end street, the consequence may be that the town is no longer big enough for the former independent and the larger system, said George Conomikes, head of practice consultants Conomikes & Associates, in San Diego, California. “Doctors caught in hospitals are stuck. Their only option is to leave town because they signed a no-compete agreement. They have to move 50 miles and start from scratch, and it’s very tough to do that.” They may also need a consensus from the other physicians who joined the hospital with them, and some of those doctors may be highly content and unwilling to start over. “Those other guys may not be as unhappy. They might say, ‘Oh, God, what a relief. All I have to do is come to work, see patients, and go home, and not worry about the overhead and all this other stuff.”

Finding the right partner can lead to a much higher level of practice for physicians, as well as broader responsibilities that add fulfillment to oneâ€™s career.

Pursue Mergers, Affiliations With Both Eyes Open

Though they often lend strength to oncology practices by combining through mergers and affiliations, radiologists are feeling pressure to demonstrate the importance of their work, as the value transition brings increasing scrutiny to levels of waste, inaccuracy, utility, and technological sophistication in their trade.

Speakers planning to present at the upcoming American College of Radiology (ACR) conference in Washington, DC, May 15-19, said that the value transition is leaving no stone unturned.

The value transition is reaching into large medical institutions as well as smaller, independent practices, said James Rawson, MD, a diagnostic radiologist and chair of ACR’s Commission on Patient- and Family-Centered Care, who practices at the Medical College of Georgia at Augusta University, where he serves as department chair for radiology. It’s important for radiologists to reassess their activities to more clearly define and enhance the value they contribute to the medical process, he said.

“That value could be improved outcomes, it could be lower cost, it could be better patient experience; but, our challenge is to figure out how to increase and improve the value. I think, like everybody else, we’re in the middle of this,” Rawson said.

Radiologists have a vital role in the medical establishment, and, in some cases, they are more upto- date in their use of technology than other medical personnel, Rawson said. “In radiology we have been using computerized information systems for decades, and so we’re not on version 1.0 of radiology information systems or version 1.0 of PACS. I think we bring a unique perspective as we enter into an era of population health and as we look to optimize the care of an entire community.”

Rawson trains radiology residents at the Medical College of Georgia and believes that the broad variety of skills his students are learning—medical physics, clinical radiology, process improvement, informatics, and others&mdash;are very much in demand and signify the importance of what radiologists do. “I think we have the skill sets to help optimize system performances, patient outcomes, patient experience, and actually work to lower costs. I think we’re an essential part of the solution,” he said.

Andy DeLaO, chief engagement officer of My Ideal Patient Experience and a Mayo Clinic Center for Innovation healthcare blogger who is delivering the Moreton Lecture at the 2016 ACR conference, said patient expectations are on the rise, as technology has equipped them with far more information about healthcare than before, and their demands for quality are higher, given that more of their own money is being consumed by rising copays and coinsurance.

“I think patients today are knowledgeable and informed and they want to know what they’re getting for the money they’re spending,” DeLaO said. He is a believer that the value change has its roots in the now-highly connected economy that enables patients to obtain good quality healthcare information very rapidly through their electronic devices, leading to levels of discretionary healthcare shopping that did not exist before. “I’m not sure that most people working inside of healthcare would agree with me, but that’s my perception of it,” DeLaO said.

DeLaO said he has had extensive involvement in the development of hospitals and cancer centers, and in renovating and expanding oncology service lines and facilities.

Appropriateness of care was mentioned by both Rawson and DeLaO as an important measure of radiology performance. DeLaO said that satisfying this objective can take the form of quality improvements that include correct interpretations of radiology work the first time around, leading to a decrease in healthcare expenditures. “When a patient comes in, the definitive diagnosis is generated by the radiologist, the pathologist, and that drives the rest of the treatment decision. I think that’s part of the story that needs to be told, and they need to demonstrate that.”

	Patients Should Receive More Information About Findings

Integrating successfully with the efforts of other professionals is also key. DeLaO recalled a broad collaborative effort, in which he participated, that led to the achievement of a 72-hour maximum turnaround from patient arrival to an understanding of potential treatment options for that individual. “The only reason that happened was due to our ability to to share the information from radiologists and pathologists with medical oncologists, radiation oncologists, and surgical oncologists and vice versa. This cross-flow of data enabled all physicians to understand that they were running the right tests, at the right time, to satisfy the need for useful data, said DeLaO, who declined to name the healthcare organization involved.

Patients need to be shown in other ways that they are getting value from the radiology staff, DeLaO said. One possible way of doing this could be providing a simple sheet of paper to patients following an exam that has the word “radiology” on top and states “this is what we found,” with key issues identified and an invitation to ask questions, DeLaO said. Such an offering also could be made via mobile phone.

Such initiatives can help to bring the work of radiologists into the open, DeLaO said. “For too long, the conversation about the value of what radiologists do has been controlled by the referring physicians, or it has been controlled by the specialists.”

One further step can help to win over patients, DeLaO said, and that is to engineer an in-house cultural transition that boils down to what he calls the “Four T’s”: Time, Trust, Transparency, and Transition. “Radiologists need to understand how you can allot the right amount of time with patients so that you are building the trust, which leads to a transparent conversation, which then helps you to manage transitions in the journey of healthcare.”

Rawson said that there is a great deal of adjustment ahead for his profession. “I think there are good tools being developed to help us make better decisions and better recommendations, and integrate in a more efficient way as part of our dictations and our radiology reports. Those may be challenges, but I think we are up to facing those challenges, and solutions are being developed to do that.

Though they often lend strength to oncology practices by combining through mergers and affiliations, radiologists are feeling pressure to demonstrate the importance of their work, as the value transition brings increasing scrutiny to levels of waste, inaccuracy, utility, and technological sophistication in their trade.


Radiologists Feel Need to Speak Up About Value They Bring to Oncology

Despite all you hear about the war between specialty pharma and the independent oncology practice, it is possible for some independents to turn their in-house pharmacy operations into growth machines. Such a feat has been accomplished by Florida Cancer Specialists & Research Institute, a growing chain of independents that told 

 for this month’s issue that the oral oncologic side of their business now represents 35% of their in-house pharmacy and could very well reach 50% in the next five years. This achievement with orals comes despite the efforts of specialty pharma and other industry players to capture new drug revenues by establishing single-source distribution.

FCS is a group of 90 practice locations and roughly 190 physicians that has come to dominate the Florida market for cancer services. It represents the largest independent oncology group in the country. Much of the growth in pharmacy at FCS stems from transformation of in-house dispensing activity at independents that joined the group. Previously, many of them did not dispense orals. That changed when they joined FCS. In addition, many wasteful practices were eliminated, including white-bagging. The practice of obtaining pre-paid drugs directly from specialty pharma for administration in doctors’ offices typically does not generate revenue for the physician but does add to the workload and leaves the physician liable for outcomes. Those interviewed by 

 for our story this month on in-house pharmacy said they eschew this practice.

Among independents, FCS is leading the way on in-house pharmacy emphasis. They are building this business hand-in-hand with the development of their value proposition for the new age of cost-conscious, patient-centered care. When they go to payers and drug manufacturers with the argument that they should retain dispensing rights for new oncolytics, they make sure to mention that, as independents, they are cheaper than hospital systems. They also contend that by administering drugs they remain in control of the care process from start to finish, thereby ensuring a level of involvement and quality that specialty pharma may find hard to match. The next step of the value argument, of course, is proving that these assertions are correct—that quality of care and outcomes are indeed better and less wasteful. FCS is working on that, too.

As previously stated, this effort is paying off. Here is what Ray Bailey, RPh, pharmacy director for FCS, told 

 “When I came here six years ago, there was only a handful of drugs in the dispensary. I could see it on the horizon. The practice did. Our board and managing partners saw the potential out there, but I don’t think any of us thought it would get that big. I didn’t.” There’s potential for further expansion of in-house pharmacy, he said. “I think if you look at targeted therapies, it’s not just orals. There are monoclonals, and immuno-oncology, and, potentially, nanotechnology.”

Amid all of the talk of 340B drug program inequities, the talk of crushing pressure from large institutional players, such a level of optimism cannot help but be a shot in the arm for struggling independent oncology practices. Read all about this—and more&mdash;in this month’s 

Despite all you hear about the war between specialty pharma and the independent oncology
practice, it is possible for some independents to turn their in-house pharmacy operations into
growth machines.

February 2016 | Oncology Business News®

Second Partnership Was the Charm for Seattle Oncology Practice

Bankruptcy in Cancer Survivors

In-House Pharma Feeling the Pressure From Drug Industry Competition

Pursue Mergers, Affiliations With Both Eyes Open

Radiologists Feel Need to Speak Up About Value They Bring to Oncology

Growth Spurt for In-House Pharmacy at Florida Group