Midwest Oncology Practice Succeeds With Independent Spirit

Shaker R. Dakhil, MD

The partners at Cancer Center of Kansas (CCK) have heard for years about all the radical changes they must make to survive as a business. They have implemented those changes required by law, but they have stood firm against fads. CCK has not transformed itself into an oncology medical home (OMH) or any other cookie-cutter form of practice. And it’s doing just fine, its administrators say. “We’re cutting edge in the treatment we offer. We change our protocols the minute research justifies change, and we participate in an extraordinary number of trials for an independent practice in rural America,” said Shaker R. Dakhil, MD, the practice’s managing partner, who is considerably less open to tinkering with CCK’s business model than he is to clinical improvements.

Some of the newer oncology models would result in a lower quality of care, he says. “The single biggest requirement to be certified by today’s ‘quality’ initiatives is to divert resources away from the care of actual people and toward the compilation of absurdly detailed reports. The idea that better records equal better care is silly, just like the idea that better care will keep cancer patients from using emergency rooms. Better care can certainly help, but the primary driver of cancer patient hospitalizations isn’t avoidable emergencies, it’s socially driven issues such as patients having no caregivers or caregivers being overwhelmed. More paperwork is not usually the answer.”

CCK opened in 1975 as a single-doctor, single-office practice called Wichita Hematology/Oncology Group. Founder Harry Hynes, MD, had recruited 3 oncologists by 1981, when Dakhil joined him. The practice now has 15 oncologists and a total staff of approximately 240, all distributed among 2 offices in Wichita and 19 others spread across southeastern Kansas. All of the offices employ nurses and other full- time support staff and 2 offices outside Wichita have oncologists full time. Oncologists based in Wichita visit the remaining offices once or twice a week.

Most of the satellites are close enough to be easy daytrips for the Wichita-based physicians who share the responsibility for visiting the smaller offices, which may be hundreds of miles away. East to West, Kansas measures over 400 miles. Access to the most far-flung of CCK’s satellites generally requires a long drive through the early morning darkness, a day at a remote office, a night in a hotel, a second day at a second remote office, and then a long nighttime drive home.

Technology has made it considerably easier to manage so many small offices. The practice’s electronic health record (EHR) system has eliminated the need for physicians to ferry paper records. The office-management software allows the practice to centralize nearly all administrative work in Wichita. And the centralized phone system funnels all after-hours calls to a single on-call physician, who can use the EHR to get access to the records of each patient who calls.

This connectivity comes at a huge price, though. Many of the towns that CCK serves don’t have broadband. The practice has had to pay internet service providers to lay the wires it needs, and its monthly telecommunications bill runs to $24,000. Another big cost associated with CCK’s satellite system is the need to staff each office full time with enough oncology-certified nurses (generally 2 to 3) to handle peak-hour patient flow.

CCK tries to compensate for those outlays by renting relatively modest buildings rather than fancy offices. The practice has little need to impress anyone with its offices because administrators believe that quality care is enough to attract patients. The practice also faces no competition in most of the places it serves, and that is no accident. CCK has avoided opening an office in any town that already has a medical oncologist, and it has avoided duplicating any services offered by local hospitals. “There’s no need to open an office in a town where people can already see an oncologist because there are so many towns that have no oncologist at all. Those towns will quite literally come to us and ask us to open an office,” Dakhil said. “We also stay away from surgery entirely, and we only offer radiation at one office where it’s not offered by any nearby hospital. We work with our local hospitals, and those partnerships are good for them, good for us and good for patients.”

Although CCK has mostly been able to escape the sort of institutional competition that threatens many independent oncology practices elsewhere, the steady growth of new regulations has been a major challenge.For many years, partners and administrators dealt with most legal issues as best they could and referred the most complex and important issues to a local law firm. Eventually, the partners made a choice that Dakhil believes every midsized practice should consider: they hired a full-time lawyer for the firm. “When most people think about lawyers in a medical context, they think about malpractice suits, but I’m not a litigator, I’m a transactional attorney. We’ve had virtually no malpractice suits over the decades, and even when we have, outside counsel is hired in collaboration with the insurer,” said Laura Monahan, CCK’s chief legal officer. The tasks of regulatory compliance, drafting, managing and negotiating documents, and risk management are enough to keep her fully occupied.

In addition to these high-priority legal matters, Monahan is an instrumental part of the management team and provides CCK with legal perspective on day-to-day management and business decisions. “Practicing medicine is like walking through a legal minefield,” she said. “Most providers know they’re heavily regulated, but most of them don’t realize how far it goes. Regulations govern what you must say and do and what you cannot say and do. And the regulations keep changing, which makes it nearly impossible for people with other jobs to keep up. There’s also all the additional legal work associated with negotiating contracts with payers and landlords and vendors.”

Before Monahan arrived, CCK administrators and managers lived in dread of audits and inspections—not those of a financial nature but those designed to look for missing paperwork. Papers documenting required employee training might take all day to find, and tempers on both sides tended to flare. Having a lawyer on staff ensures that current and complete legal documents are instantly available and that administrators and physicians can do their jobs. Better still, the money the practice has saved on legal fees more than pays for Monahan, who previously handled CCK’s account for the practice’s outside counsel.

One of Monahan’s most important roles is keeping everyone at CCK abreast of proposed regulations that might change the way the practice provides care. The practice has long struggled with rules that make it hard to operate very small offices. For example, CCK is concerned about USP 800 pharmacy rules that would impose stringent new physical plant requirements for the mixing of chemotherapy drugs, a rule that would create a very large compliance burden for small-town practices.

Rules on drug handling also have complicated CCK’s ability to offer clinical trial access to its patients. CCK doctors have been driving experimental medications back and forth across the state of Kansas for decades now because it’s the only way to avoid running afoul of regulations that disallow shipping such medications directly to the offices where they’re needed. As a result, CCK has as many clinical trial patients as any practice its size and can boast that it provides cutting-edge care, even if it remains skeptical about what others believe to be the cutting edge of care delivery models.