Hospital-based oncology services, long a mainstay business line, face many challenges as some of those services migrate from hospitals to outpatient surgery centers, physician offices and even to patient homes. Newer drugs, safer surgical procedures and advanced imaging and radiation technology have brought new tools to cancer experts.
While some chemotherapy infusion has been leaving hospitals for years, federal regulators have now allowed some to be performed in outpatient settings.
But healthcare consultants, hospital administrators, pharmacists and physician oncology experts say there remain plenty of opportunities for hospitals to hold onto and even expand their market share. The cost of some technology is more easily absorbed by hospitals and some have joint-ventured with physicians to delivery high quality, state of the art cancer care.
Here are 12 best practices from 10 respected oncology experts on how hospitals can improve the quality, efficiency, patient satisfaction and financial health of hospital oncology programs.
1. Consolidate oncology services into a single center focusing on cancer care. Goshen, Ind., was probably best known as the hometown of Jazz-Era writer Ring Lardner. Not anymore. Now patients come from five states to this Northern Indiana city of 30,000 to access world-class care in a hospital cancer center led by a former National Cancer Institute official.
James Dague, president and CEO of the Goshen Health System, said the hospital had three weeks of cash in reserve 14 years ago when its board decided to invest in building the Goshen Center for Cancer Care, which opened in 1998. The 30,000 square-foot facility offers separate entrances for the cancer program and the Goshen Hospital's inpatient unit for oncology patients.
"It's a convenience aspect for patients, a kind of one-stop shopping," Mr. Dague says. "Patients can come to one site and complete all their physician appointments, review their treatment plan and have their lab and diagnostic tests in one place, something really difficult to do in multiple settings."
He says the cancer center has become a regional cancer treatment facility, a destination hospital that has grown by 17-22 percent annually since opening. Mr. Dague says the staff was lured by Cancer Center Medical Director Douglas Schwartzentruber, MD., a surgical oncologist and former official with the National Institutes of Health and the National Cancer Institute.
"The hospital is experiencing a halo effect from the cancer center," Mr. Dague says. "The hospital is seeing more types of patients because of the quality reputation the cancer center has created."
Mr. Dague says the cancer center generates about 30 percent of the hospital's revenue, contributing significantly to the hospital's $9.8 million net income on 2008 total revenue of $190 million. He says the cancer center's integrated, multi-disciplinary delivery model and focus on research and evidence-based protocols have attracted clinical trials from drug and medical equipment producers, programs that not only generate revenue, but allow patients to benefit from cutting-edge science and technology.
"We treat the whole person in one setting, not just with conventional modalities of specialty and sub-specialty care that includes radiation, oncology, surgery and the latest diagnostic imaging equipment, but also their family, social and spiritual needs," says Dr. Schwartzentruber. "We can only cure a limited number of patients with cancer, but we can offer healing to everyone."
2. Build the cancer program around the patient. Every Monday morning specialists and primary care physicians meet at the Goshen Center for Cancer Care to discuss cancer patients. Every Wednesday all the players — nurses, physicians ranging from radiologists to naturopaths, nutritionists, physicists, counselors and others — meet to discuss each patient's care.
"It's a coordinated approach that has worked well for our patients," Dr. Schwartzentruber says, pointing out that Goshen's cancer center routinely records patient satisfaction score averages that exceed 95 percent. "We're giving the patients what they're asking for. Our healthcare system is so fragmented and harried that in most hospitals doctors are lucky if they talk to each other at all."
The meetings not only connect the healthcare providers to focus on patient progress, but also serve to coordinate care to reduce errors and improve quality.
3. Adopt a salaried physician model to focus on cancer care. Goshen Center for Cancer Care employs a salaried physician model, which Dr. Schwartzentruber says removes some incentives for doctors to over utilize testing or skimp on spending time with patients.
"You have to bring value to physicians," he says. "It has to be more than an income. With increasing regulations, quality reporting data and financial pressures, the more you can remove those burdens from physicians, the happier they are. If you can provide a mechanism so they can practice medicine, conduct research and create an excitement for the practice of medicine, that is a value physicians are willing to accept. And the decreasing reimbursements paid to physicians diminish some of the allure of entrepreneurship. The focus of our physician staff is on quality and innovation and excellent patient care. The business side I leave to our administrative team. We know we can focus on patients and do what's right. And if we put quality first, the rest will follow."
Dr. Schwartzentruber says the salaried physician model also eliminates the inevitable turf battles that result when physician specialists compete for patients.
"Our care team members gather to decide the best course of treatment for patients and there's no competition because there's no economic incentive," he says. "The physicians don't own any of the equipment. And whether the surgeon or urologic oncologist gets the patient doesn't affect their salaries. We've taken the competitive financial pressure out of the decision-making process to find the best course of treatment for that patient."
4. Recruit cancer sub-specialists to develop and grow niches in breast, melanoma, prostate or other cancers. Jim Unland, president of the Chicago-based Health Capital Group and a longtime hospital financial consultant, says bringing in cancer specialists and sub-specialists allows hospitals to maintain and even grow market share. Mr. Unland says that patients will travel to find high quality specialty care, noting that quality specialists attract patients, both locally, regionally and nationally. He says patients have grown more sophisticated in navigating the health system and use the Internet, medical libraries and online support groups to access information.
"Generally the physicians are attracted to our delivery model," Dr. Schwartzentruber says. "As our team has grown at Goshen's cancer center, we've brought in physicians with unique specialties. I'm primarily treating patients with melanoma, which comprises something like 4 percent of all cancers. But we get people from all over to come here. We also offer a unique type of radiation treatment for liver cancer and have received referrals from around the country, even from overseas. We offer technology that not all places have and we have trained staff that knows how to use it. When we bought a particular robot, we also brought in the urologic oncologist at the same time who is considered an expert on it."
5. Review hospital chargemasters to insure that claims for chemotherapy drugs are billed correctly by increment. Ernest Anderson, president of the Association of Community Cancer Centers (ACCC) and the director of pharmacy for the Burlington, Mass.-based Lahey Clinic, says many hospitals lack systems to verify that their filed claims are correct. Because of that, many are underbilling and leaving money on the table. Mr. Anderson says sometimes the hospital chargemaster is the culprit.
"With the high cost of cancer drugs, we need to make sure hospitals are maximizing reimbursement by billing correctly," Mr. Anderson says. "It is a relatively complex process and small errors add up to a lot. We need to make sure the increments are set correct and billed appropriately."
6. Thoroughly understand the cancer care revenue stream. George Kovach, MD, a medical oncologist and partner in Davenport, Iowa-based Hematology Oncology Consultants, says too many hospitals narrowly define the revenue stream produced from oncology.
"They just look at chemotherapy, but that's just one piece" of oncology, says Dr. Kovach. "They need to consider consults and admissions and X-rays and surgical services, radiation therapy, you count that whole thing as part of your revenue stream. The key thing is not duplicating services, having multiple this and that. You need to build trust."
Dr. Kovach is one of six oncologists on staff at Genesis Health System in Davenport, which operates a private practice within the hospital performing infusion therapy.
"The hospital owns everything and we rent space. The trust we share is not an anomaly," he says, explaining that changes in reimbursement for infusion therapy mean physicians can lose money treating some patients.
"We try to do as much as we can, giving the hospital some solid business in exchange for sending them indigent patients we lose money on," he says. "Because if the hospital loses money, patients will go untreated and it will create a bigger problem for everyone. We try to give the hospital winners along with losers. Anyone who tries to dump on hospitals without tempering those losses with good-paying referrals will cause strains."
7. Closely examine billing rejections to learn why claims are denied. Mr. Anderson of ACCC says bills are sometimes rejected by payors because they are generated by two or more different hospital computer systems, such as pharmacy and nursing. Mr. Anderson says that even though claims may be valid and the services were performed and delivered appropriately, payors could still deny them.
"Often it's because something was misdated, particularly relating to billing for injections. If they were not billed for the same date, one component could be denied," he says. "We've corrected our processes to ensure dating is appropriate and always matches. It's bad enough that reimbursement is low, but if hospitals are billing incorrectly, that's a sin."
8. Keep a clinical fact sheet protocol on every patient. Ed Zagol, associate director for clinical oncology at Jordan Hospital in Plymouth, Mass., says that fact sheet records when the patient was last treated and when the next treatment is due, what is prepared and other descriptions that improve the efficiency of the chemotherapy treatment process.
"We try not to miss a patient," Zagol says. "Before we implemented the schedule, we didn't know when the patient was due next for treatment. Now a reminder is a part of the process."
Mr. Zagol says another component of Jordan's program is an advanced order program that allows chemotherapy patients to telephone their arrival time so their drugs are ready when they arrive.
"There's no lost time in the waiting room while the preparation is done," he says. "The patients like it because they feel in control of their chemo process and appreciate not having to wait. Chemo mixtures can cost $2,000 to $3,000 and are targeted for a particular patient, so we don't want to prepare it in advance unless we know for sure that the patient will be there for their treatment. We have to be fiscally responsible.
"It also reduces waste," Mr. Zagol says. "Patients know that by calling in advance they won't have to wait, so there's an incentive for them to call, and most do. One patient comes in five days in a row. I arrive at 6:30 a.m. and at 6:31 a.m. he calls."
9. Invest in healthcare technology. Janet Nelson, a veteran oncology nurse, practice consultant and executive who now serves as the chief operating officer of Dallas-based NexGen Oncology, says partnering with physicians is key to the success of any hospital oncology program.
"And to do that you must have cutting-edge technology tying together medical records across the patient care continuum, technology that can access insurance information, PET scan and X-ray results and the latest lab tests in a platform in which all the clinicians can interact and share information in real time," she says. Ms. Nelson says NexGen is "heavily invested in clinical infomatics," which she calls "the new front end to the oncology experience."
She says having that system enables NexGen staff to broaden its geographic reach and participate in telemedicine initiatives.
"Investing in technology is a huge expense, but it will improve efficiency, quality and the patient experience," she says. "America's healthcare system is still set up in silos now, but this is the model of the future."
10. Use patient navigators to improve patient satisfaction. JoAnn Lovins, director of oncology services for Poudre Valley Hospital in Fort Collins, Colo., says patient navigators, who are oncology nurses that connect patients to transportation, social services and work with them on co-pays and other insurance issues and access to drugs, optimize how patients get through the cancer treatment process.
"With the support services and funding, it's almost too much for patients to handle," Ms. Lovins says. "Patient navigators make the whole process easier to handle, more efficient and end up paying for themselves. A new cancer patient averages 70 visits the first year of diagnosis from the first screening. When we listened to the voices of our customers, we heard that the handoffs and connections were difficult. Finance becomes an issue very fast. Our doctors were saying we need an oncology nurse available 24/7 to hold patients' hands and we listened to our physician partners. There are many barriers. And the primary mission of patient navigators is to remove barriers and enhance timely access to cancer care, to help them through the struggle."
Ms. Lovins says Poudre Valley secured $250,000 in foundation grants to assist patients with drugs, daily life expenses and payments to doctors and the hospital.
"If patients need to go from commercial insurance to government insurance, we help to move them along in a timely fashion," says Ms. Lovins. "When I had to justify these positions, I showed that the income coming in from having these navigators helps us access grants to directly cover treatments, instead of having these patients going on charity care. Our physician partners benefit, too."
She says Poudre Valley, the only U.S. hospital to win the coveted Malcolm Baldridge Award (from the U.S. National Institute of Standards and Technology) in 2008, hired oncology nurses as patient navigators "because they know how difficult the process can be."
11. Reduce delinquent billing. Herb DeBarba, the vice president of Lean Operations for Schaumberg, Ill.-based Cancer Treatment Centers of America (CTCA), says the company cut its delinquent billing by 93 percent by reducing the time and error associated with billing and coding.
"We did that in less than 26 days by monitoring the time from when service was rendered to the time when the account was charged and tracked that accuracy rate," Mr. DeBarba says. He says the privately-held firm, which has adopted Six Sigma and Toyota's "Lean" continuous quality improvement programs, moved to 'real-time charging,' also known as posting. Previously it sometimes waited until the end of a shift or the next day to bill a claim.
"If we can streamline quality activities together without the waiting time, the accuracy is much improved," says Mr. DeBarba, who points out that CTCA has reduced the actual time it takes to bill a claim by 33 percent.
12. Expand infusion center capacity. CTCA's Mr. DeBarba says the company increased the capacity of its infusion centers by 32 percent without staffing increases by examining and streamlining its processes by using a value stream map, a process map that identifies value-added steps.
"Once we identify what's not of value, we work to eliminate it," he says. "Now when a patient walks into one of our infusion centers, he or she is greeted by name, a patient care technician is immediately summoned and can begin vitals right away. The patient care technician introduces the patient to the infusion nurse who lets the patient select a chair, and within 20 minutes of arrival we can hang the infusion bag. We've reduced waiting time and improved handoffs and patient satisfaction. We are relentless in pursuit of customer intelligence"
He says there are financial benefits to providing excellent care. "But that's not why we do this," Mr. DeBarba says. "When you eliminate non valued-added activity, not only do your costs go down, but you improve patient loyalty."