As few as 5,000 community oncologists care for upward of 80% of the nation’s patients with cancer. According to Chris Beardmore, CEO of Translational Research Management (TRM), this vital group of community practitioners needs to use extreme caution or face an untenable loss of revenue.
Speaking at the 37th Association of Community Cancer Centers (ACCC) Annual National Meeting in Washington, DC, Mr. Beardmore said that since the passage of the Medicare Modernization Act of 2003, declining reimbursements began a slow, but ineluctable trend in community cancer care. “If you reimburse oncologists with an average sale price model plus 6%, you need to assume that every practice is on equal footing, which isn’t the case. Larger group purchasing organizations are getting better pricing, perhaps 1% to 2%. That means that the margin for a midsized or small oncology practice is as little as 3%.”
Mr. Beardmore explained that if a practice fails to sufficiently collect from patients and insurance companies to guarantee that they get that needed percentage of markup, the chemotherapy debt incurred has the potential to drive the entire practice underwater. This shaky reimbursement scenario plus a rising competitive bar with the growth and development of “super-regional” cancer centers is reshaping much of the community landscape.
Physician-Hospital Relationships
In the 1990s, community cancer centers experimented with oncology practice acquisitions. While aspects of that trend went quite well (in that they were certainly better equipped to provide coordinated multifaceted care), for a variety of reasons those relationships began to break apart, and oncologists who were working at community hospitals went into private practice.
The ongoing health-care debate is once again raising the possibility that community oncologists will return to the hospital practice environment. “The current financial pressures they’re feeling, along with perceived opportunities presented by accountable care organizations, are ultimately bringing them back into a position where they may need to develop a relationship with a hospital,” said Mr. Beardmore.
He said that in today’s environment it is important to structure novel physician-hospital relationships so that the community oncologist can get the benefits of collaboration. “Moreover, to ensure that patient outcomes are continually improving, participation in complex clinical trials is ever so important,” said Mr. Beardmore.
At the same time, Mr. Beardmore cautioned that a physician-hospital relationship does not have to follow an ownership model. “Community oncologists are fiercely independent, and I’m not entirely certain they want a fixed salary and to be put into a position in which the hospital influences their clinical autonomy,” said Mr. Beardmore. He added that a well-structured physician-hospital relationship provides clinical and financial value to community-based physicians and improves clinical collaboration, but does not affect the doctor-patient relationship.
Research Hubs
One long-standing issue in oncology is lack of participation in cancer clinical trials. The American College of Surgeons Commission on Cancer Program Standards found that only 2% to 4% of adults participate in clinical trials and a worrisome 84% of patients are unaware of this treatment option.
Mr. Beardmore said that phase I and II trials have extensive time elements involved in collecting samples (pharmacokinetic, pharmacodynamic, pharmacogenomic), and in some instances they require that the participants be in a health-care facility for up to 10 hours a day. The inherent complexity of these trials and the attendant burdens placed on the providers and their patients work against the system.
“The general idea behind TRM is that we can actually form a novel relationship between a community cancer center and a group of community oncologists, in which complex phase I clinical trials are coordinated and carried out within the ‘hub’ facility,” said Mr. Beardmore. “As trials move to phase II or III—studies that do not involve intensive sample collection—they can be integrated back to the community practices where the patients are ultimately going to be treated.”
“What I foresee is a synergistic environment in which the hospital basically provides the centralized support system for early and complex studies; but when it comes to first- and second-line care of patients or research in the adjuvant setting, the study would be conducted in the community setting, because this is where most of these patients would prefer to be seen,” said Mr. Beardmore.
He stressed that by using this synergistic approach, community practices do not lose valuable revenue stream or the hands-on continuum of care they would by sending their trial patients to academic centers.
Nationwide Networking
“We’re spending a great deal of money to conduct clinical trials, and a lot of those precious research dollars are being wasted on redoing certain activities multiple times. However, we can decrease much of that waste by coordinating a nationwide network of our clinical trial sites,” said Mr. Beardmore.
“The first step is to establish a master agreement that would cover hundreds if not thousands of study sites. Then we can get rid of the excess time negotiating issues like indemnification language, which really doesn’t change from trial to trial,” he said.
“The second important benefit of the network,” continued Mr. Beardmore, “is that we can begin to identify costs at ancillary service providers, such as the cardiologists doing echocardiograms, radiologists doing CTs, or the labs that are running specimens. This would give a better estimate of the total cost of the trial prior to design and launch.”
According to Mr. Beardmore, a nationwide network would also remove much of the excess time spent on prestudy visits and clinical trial agreements, focusing that energy on what the budget is going to be for the study, the site initiation visits to train physicians to properly implement the trial, and the quality of forms and systems used to request medical services in support of a clinical trial.
“As we move toward comparative effectiveness research and personalized medicine, we are going to see trials that are incredibly focused, and patients are going to be selected because their cancer expresses certain characteristics. A nationwide network would help accrue large enough numbers of select patients across the system to conduct this vital clinical research within a shorter time period,” concluded Mr. Beardmore. ■
Financial Disclosure: Mr. Beardmore is CEO of Translational Research Management, a company interested in creating a nationwide community oncology research network. In addition, TRM supports the conduct of industry-sponsored clinical trials at network sites. He has no ownership in the community oncology sites, the biopharmaceutical companies he works with, or the products being tested.
