Unionized Town Simplifies Management for Nevada Practice

James D. Sanchez, MD

When James D. Sanchez, MD, moved to Las Vegas and joined the practice that’s now known as the Comprehensive Cancer Centers of Nevada (CCCN), he hoped to trade Ohio’s cold winters and economic stagnation for ample sunshine and rapid growth. He knew Vegas was booming—its population has surged from 1 million to 2 million since he arrived—but CCCN’s proportional growth has been much greater. The four-physician practice where Sanchez began has become a 50-physician practice with 15 offices in southern Nevada and northern Arizona.

CCCN’s exponential expansion is, in part, a result of both the surging local headcount and the national trend toward oncology practice consolidation. “As our city has doubled in size, the need for oncologists has more than doubled. We don’t just need twice as many people offering the services that patients could get here before. We also need specialists who can offer patients here the sort of unusual treatments we could not offer here when the market was smaller,” said Sanchez, who is now the practice’s president.

The practice’s growth is also a reflection of an ambitious vision: to make CCCN a cancer treatment hub for patients from across the country. “Continued growth of the local population will further increase our ability to provide specialty care in the city rather than sending patients to major cancer centers elsewhere,” Sanchez said. “In fact, we hope that Las Vegas will evolve into a destination for cancer treatment. There are two university-affiliated medical schools that will be opening their doors soon, and we hope to work with them and the local hospitals and existing partners to become a world-class cancer hub—a hub with the sort of amenities that would naturally make traveling patients choose us over other places.”

In many ways, CCCN’s growth mirrors that of other successful practices in other big cities. It started as a partnership between medical oncologists, who then joined forces with radiation oncologists, surgeons, and pulmonologists to provide integrated care to patients who needed multiple treatment types. It also teamed up with academic institutions and pharmaceutical companies to offer patients access to clinical trials and has opened its own diagnostic labs and CyberKnife center.

As the practice grew, it continued to open new offices across Las Vegas rather than concentrating its resources in one or two large facilities—a strategy that saves very sick patients from long drives and maintains the personal feel at what is actually a large organization. In other ways, CCCN’s choices reflect the quirks of its home market.

The geography of Las Vegas is almost entirely manmade, and it is dominated by the one part of the city that nearly everyone knows: Las Vegas Boulevard (aka The Strip). That most famous of roads, which is paralleled a block to the west by I-15, makes east-west travel nearly impossible for much of the day.

Working With Self-Insured Unions

Although the 27-mile drive from Sanchez’s home to his office takes less than a half-hour early in the morning or late at night, it can easily take two hours at other times. CCCN keeps this in mind when it chooses office locations. The north-south distance between practice locations, which is easily driven, tends to be substantial, but the east-west distance may only be a couple miles.Las Vegas is also unusual, at least among big cities, in having a single industry dominate its economy and having so many of its residents belong to the handful of unions that service the resort casino industry. Those unions are large enough to set up self-insurance plans for their many thousands of workers, and they negotiate directly with service providers such as CCCN.

“Las Vegas may be the biggest small city in the world. It has a huge population, but a handful of casino executives and union officials make a lot of the decisions that affect life for everyone here. Having a reasonably close-knit group with deep roots in the community provides an opportunity for businesses that also have deep roots in the community. It gives you the chance to talk to the people who make decisions rather than dealing with middle men,” said Sanchez. “For example, we have a direct relationship with the culinary union, which funds its own health insurance, and that union is easier to deal with than almost any health insurer. There are never any surprises from them, and we try to make sure they’re never surprised by us.

Slow Payment Leads to Withdrawal From Co-op

If an issue comes up, we call them to discuss it. It usually takes us hours to settle issues that would take days if we were dealing with an insurer.” CCCN’s dealings with some of the local health payers have not gone nearly so smoothly. The practice made news a few years ago when it stopped participating in the area’s two big HMO networks. CCCN has since added seven local oncologists who continue to treat HMO patients; however, the group’s other oncologists still do not take HMO patients from Sierra Health or Health Plan of Nevada.CCCN also opted out of an agreement with Nevada Health CO-OP in 2014, a move that put the practice out-of-network for all Nevadans who purchase health insurance through Affordable Care Act exchanges. The decision drew some criticism at the time, but Sanchez said the co-op took as long as three months to pay claims. “It’s like being a bank. You loan out money, and if people don’t pay you back, it’s difficult to run a business and stay solvent,” Sanchez told the Las Vegas Review-Journal at the time. “We need to be there for the rest of our patients.” The co-op shut its doors in December.

CCCN takes all the other big local insurance plans, but Sanchez characterizes the relationships with some payers as frustrating. Several payers routinely try to deny claims for treatments that are standards of care advocated by the National Comprehensive Cancer Network (NCCN) on grounds that those treatments are “experimental,” and one insurer seems to have adopted a policy of denying all claims related to imaging. CCCN and its patients usually win coverage on appeal, but Sanchez says such hindrances routinely delay patient diagnosis and care. Such payers are the exception.

Clinical Trial Offerings Lead to Overwhelming Response

Except when they are explicitly participating in research projects, all of the practice’s physicians stick to the standards of care advocated by authorities such as the NCCN; and that, Sanchez says, leads most payers to grant speedy approvals for diagnostic tests and treatment proposals.Of course, insurers rarely finance the large amount of genuinely experimental work that goes on at CCCN, but the practice gets paid for that work by the research organizations and pharmaceutical companies that sponsor the trials. CCCN began offering patients access to some trials more than 20 years ago, when it established a partnership with the University of California at Los Angeles. The response from patients was overwhelmingly positive—patients with poor prognoses jumped at the chance for something better—so CCCN began working to give patients more ways to participate in trials. The group now has a deep partnership with the University of Southern California and direct relationships with most large drug companies.

“Cancer care has improved to the point where many patients experience complete cure or remission. Our goal has become to support patients into a survivorship of their cancer. However, when treatment is no longer effective, patients want to know what else we can offer. They are looking for options,” said Jennifer Lucisano, CCCN’s director of clinical operations. “We are often able to offer those patients another treatment through our clinical trials program, something that really sets us apart from most other oncology practices. That is both a competitive advantage when you’re trying to attract new patients and—far more importantly—an enormous benefit to those patients.”

Participating in so many trials creates some administrative challenges for CCCN. Among them is the need to keep everyone at the practice constantly updated on which trials may be right for which patients. “Communication is key to the success of our program: we involve all staff, physicians, and patients in sharing information to make sure our patients’ needs are met. We hold regular research updates and share findings and outcomes to enhance our clinical practice,” Lucisano said. “We often get referrals to CCCN from patients seeking to enroll in a clinical trial. Our team does an outstanding job of prescreening these patients who can then make informed decisions about potential options available through clinical trials at CCCN.”

Trials are not the only unusual treatment option that CCCN offers patients. The practice works hard to live up to the “Comprehensive” in its name and offer any type of cancer treatment that patient demand will support. It also provides many of its own diagnostic tests. The medical services the practice has added over the past 20 years give it both extra revenue and the ability to coordinate multi-faceted treatments in ways that improve both efficiency and outcomes.

At the same time it has added treatment options; however, the practice has backed away from nonmedical activities. It pays The US Oncology Network to manage its administrative and back-office activities so that its partners and employees can focus on patients. “We benefit greatly from being a part of The US Oncology Network,” said Lucisano. “We are able to bring highvalue, high-quality care to our patients, with the support of the buying power and efficiencies of being part of the larger organization.”