VBCC - December 2011, Volume 2, No 7 - Best Practices

Interview with Patrick Cobb, MD, FACP

Advances in the translation of research into medical practice have improved the lives of many patients in the United States, particularly for those with cancer. In this interview, Dr Cobb describes the state-of-the-art cancer center that he and his colleagues opened last year to further transform care for patients with cancer in Montana and set an example for Cancer Clinics of Excellence.

Q: In these hard economic times, what was your motivation to build a new cancer center?
Dr Cobb: Over the past 20 years, cancer treatment has evolved from a hospital-centered specialty that re - quires a long hospital stay to a patientcentered approach that is focused on delivering care close to home. Patients prefer treatment that is readily accessible and provides a safe, comfortable environment. Recognizing these changes, my partners and I concluded that the community was ready for a new view of cancer care. To create the ideal environment, we realized we needed to relocate away from the stresses of downtown to a calm setting, where the healing aspects of nature in Montana would have a better chance to impart a positive effect on our patients.

We had several other requirements. First, the new building would have to be designed to create a caring and supportive environment for our patients. Second, it must contain the latest technology for our patients to receive stateof- the-art care. Third, it would have to be visually appealing to complement the surrounding area and reflect the best of Montana.

We added new technologies to have almost everything a patient with cancer needs to be in one convenient place. We installed the latest-generation Elekta linear accelerator to provide image-guided and stereotactic radiation treatments. We have a stateof- the-art GE CT/PET scanner, Philips CT, and GE DEXA scanners. We also have the latest in brachytherapy treatments, with a new Varian iX radiation source.

Our new center, which opened in August 2010, confirms our commitment to be at the forefront of cancer care. We also changed our name to Frontier Cancer Center—to reflect the frontier spirit of the people of Montana and Wyoming, as well as our dedication to stay on the leading edge of cancer care.

Q: Did economics play any part in your decision?
Dr Cobb: Yes. As a result of the Medicare Modernization Act of 2003, we realized that the model of oncologists giving chemotherapy in their offices, without doing other things, would not be economically sustainable. With the marked increases in chemotherapy drugs and decreasing payments for chemotherapy administration, it was no longer economically viable to offer chemotherapy only. To stay in business, we needed to offer radiation oncology and imaging, as well as social services for our patients. We now have staff to help patients navigate the system, such as a patient’s assistance program to help with housing. Our previous model of only doing chemotherapy in our office did not generate enough revenue to pay for such social services.

Q: Did you have to bring in new experts?
Dr Cobb: We had to bring on radiation oncology, which was the biggest capital investment. And adding the imaging scanner and a CT scanner was a significant capital cost as well. To keep up with the rapidly moving pace of radiation oncology, we had to make a significant investment to acquire the best technology. And that has paid off; our patients are very happy with the conveniences that we can offer them and the level of expertise. We think that our outcomes have also improved.

Q: Can you already see financial benefits?
Dr Cobb: Financially, we are certainly viable and sustainable. The biggest question is what will happen with cancer care in the future. Con - gress is talking about decreasing payments for chemotherapy drugs, for chemotherapy administration services, and for imaging. These types of cuts make us nervous.

Q: You are also a member of the Community Oncology Alliance (COA). How active are you in COA?
Dr Cobb: I was president of COA last year, and I currently lead its policy committee, so I am quite involved with COA, because I believe in the great value that the community cancer center has for patients, for payers, and for oncologists.

Q: Speaking of COA’s policy concerns, are there financial issues, such as reimbursement or the escalating cost of cancer care, that keep you awake at night?
Dr Cobb: One thing we found is that in the economics of oncology, much like in the clinical arena of cancer care, there are no guarantees.

Opening a new cancer center like ours involves bringing on new technology and taking an entrepreneurial risk. It also means putting our capital at risk, and so we would expect a return on the investment. It is wonderful to be able to make an investment in new technology that ends up helping patients—improving outcomes, im - proving tolerability of radiation therapy, helping us make a correct diagnosis— but we cannot ignore the economic realities of the oncology world.

If we ignore that, we will not be in the “business” of cancer care for very long. This is an uncomfortable topic for many oncologists. Ever since we were trained as physicians, we were taught, “If you just do the job of taking care of your patients, everything will work out fine.” But this is no longer true for private practice oncologists in the United States.

We are seeing a huge shift away from private practice groups that were very well run and were forced out because of changes in reimbursement policy: many of these community practice oncologists ended up saying, “We’re simply not viable anymore. We have to work for a hospital.” But once you move to a hospital, you no longer run things and deliver care the way you think is best. And it ends up costing more to take care of patients with cancer in the hospital, as a result of Medicare policies. It costs Medicare at least 10% more to care for patients at a hospital-based outpatient center than at a free-standing center. As for private insurance costs, it is at least 2 or 3 times more costly to take care of the same patient: the same drugs, the same doctors, and the same outcomes, for a greater overall cost.

Q: Is this an issue COA is trying to address with Congress?
Dr Cobb: Indeed, that is one of the things we are doing at COA. As an example, we supported a Milliman study that was just published in October 2011, titled “Site of Service Cost Differences for Medicare Patients Receiving Chemotherapy” (http:// tions/health-published/pdfs/site-ofservice- cost-differences.pdf).

That study compared the data of Medicare patients being treated in a free-standing cancer center with patients treated in a hospital-based outpatient center, showing that the hospital-based treatment costs 16% more for a patient with cancer, with no added clinical benefit. The results show that a free-standing center provides the same treatment for a reduced cost, without reduction in the quality of care. Yet Medicare pays the higher cost of the hospital treatment, which makes no sense. Remember, this cost was for the same drugs, same outcomes, same medical conditions, and same providers; the one difference was that treatment in the hospital-based center cost more than the treatment at the community center.

So from a cost perspective, the value of a community cancer center of a freestanding clinic is significantly greater than the value of cancer care in the hospital setting.

Another example was when the University of Pittsburgh Medical Center Cancer Centers, transferred from being free-standing centers to hospital-outpatient centers, which raised the costs to their insurer, Highmark, by 2.5-fold for the same treatments and the same treating physicians. So the value of the money being spent for the same services in the community centers is considerable. It makes no sense to pay 2 or 3 times more for the same services: this is the value of the community center that we need to push forward as practicing oncologists.

Q: This would seem like an easy argument in support of the economic sense of the smaller cancer center?
Dr Cobb: That message is finally being heard in Congress. I think that the problem we are facing with drug shortages is giving this cause some resonance. Those in Congress are hearing that from their constituents all the time. “Look, my doctors can’t get carboplatin,” or, “My doctor can’t get cytarabine,” because these are generic drugs.

This means we often cannot treat the patient on the appropriate day, or we have to use more expensive drugs that are not generic.

It all comes down, again, to economics. There is no economic incentive to use generic drugs. Until Congress fixes that, we are going to be left with the same problem of severe drug shortages. They forget that we use these drugs to try to cure people, not just make them feel better.

For example, I am currently treating a patient with testicular cancer. I need to give him cisplatin, but it is very difficult to find this drug. So, we have to use another drug that may not be as effective, or may be more toxic, or it does not have evidence supporting it. As oncologists, we get very uncomfortable with that, because we know such patients should survive if they could receive appropriate treatment.

And this is a problem across the board, in hospitals and in the smaller community center. We hear this complaint from the major cancer centers, such as M.D. Anderson and the various Children’s Hospitals, which are especially hard hit.

Q: You are part of the Cancer Clinics of Excellence. What exactly is this?
Dr Cobb: The Cancer Clinics of Excellence are a group of practices that came together about 6 or 7 years ago with the goal of trying to share best practices, and to explore how best to approach certain tumors. We found that the movement toward evidencebased treatment protocols (ETPs) for cancer made sense, and we wanted to see if we could come up with an ETP program.

After spending much time reviewing the data, we came up with regimens that we think have enough data behind them. We are now moving into collaboration with a molecular diagnostics laboratory that will look at tumors and look at the genetic profile of an individual’s cancer. The goal is to come up with recommendations for best treatment based on genetic profiling. This is being pioneered in a few places, and it has not been done on this scale before. We want to take the advances that we have gained from the Human Genome Project and apply them in the community, to give our patients the best outcomes possible.

Q: Will this be done on a national level or within the context of the Cancer Clinics of Excellence?
Dr Cobb: This would involve the Cancer Clinics of Excellence group, moving personalized medicine to a new level. For example, when a patient is being diagnosed with breast cancer, we will send a sample of the tumor to the molecular diagnostics laboratory to do the genetic profiling. Based on the gene expressions, we then may make recommendations for one of our treatment protocols. For most patients, there are multiple treatment protocols from which to choose. But using the patient’s genetic profiling, based on the personalized medicine paradigm, will allow the patient to respond better to one treatment regimen than other regimens. We want to show that this approach can be applied to all types of cancer. So, personalized medicine is the decisive thing.

Q: Is Frontier Cancer Center currently involved in research?
Dr Cobb: Yes. We have always been a participant in clinical trials that are funded and organized by the National Cancer Institute (NCI). Those trials are very important in establishing standards of care and advances in cancer therapies. Ironically, economics plays a role in this too. The payment for putting patients in an NCI trial does not come close to covering the cost of administering the trial for the patient, and the NCI funding of this has come down significantly.

In the past, we did this for the good of the patient. We were just interested in making sure that we still made progress in cancer research. Today, with the declining reimbursements for oncologists in smaller centers, we have less time to commit to this type of research.

As it stands right now, we actually lose money if we enroll a patient in an NCI-sponsored trial. Therefore, we have transitioned much of our research to pharmaceutical company– based research, which pays significantly more than the cooperative groups or the NCI-based trials. So we now do both clinical trials and those supported by pharmaceutical research.

The pharmaceutical companies have done some very important trials. The criticism 10 years ago was that they did not fund trials of good quality, and that they were self-serving, but that’s not the case anymore. The research that we are seeing today is very good, consisting of phase 1 and phase 2 trials that are involved in emerging and novel compounds. We are glad that we are able to get those trials for our patients here in Montana, where, in the past, we were not able to do that.

Q: Has the number of patients you are able to treat in the new center grown?
Dr Cobb: Billings is a city of about 100,000 people that services a very large geographic area, including eastern Montana and northern Wyoming. We have a lot more cows than people here.

We get people in from a big catchment area. Other than perhaps Anchorage, Alaska, we probably have the largest physical catchment area of any practice in the United States. This brings some challenges, but our patients enjoy coming to our place. The number of patients is stable, and may have increased a bit. There are 2 different healthcare systems in Billings, and they are competitive. That is another reason that we built the center: we wanted to give people a compelling choice, that they could come to a center that is away from the medical corridor, where they could park next to the building, and get all their cancer care in one place, as well as have access to state of- the-art technology.

We believe we have done that. Over time, we believe that when patients have a choice which cancer center to come to, they will ultimately choose ours.

Q: What are some of the lessons from your experience as a centralized cancer center?
Dr Cobb: Our experience has worked out very well for our patients. There is no question that our patients are best served by cancer care that is delivered in one place, where they can get all their imaging, radiation, and chemotherapy needs; where everybody can collaborate in one spot. The bigger question that is going to come up in the near future is whether this type of free-standing cancer center is going to be economically viable. So far it has proved to be, but we are concerned about potential policy changes.

The economics should be compelling enough to keep us in business, because the research shows that we are less expensive than a hospital outpatient center for Medicare, and we are markedly less expensive for our private insurers. The data clearly show that free-standing outpatient cancer centers provide more value than hospital-based cancer centers. Whether insurance companies and Medicare agree with this conclusion and move quickly to change payment models to keep private oncology practices economically viable remains to be seen.

The biggest thing for an oncology practice to understand is the way in which what is happening in Washington, DC, is going to affect them. Oncologists need to take an active role in educating their senators and representatives about the effects of federal policy on practicing providers.

Getting involved with COA is an excellent way for oncologists to be able to define their message, and to keep in touch with their congressional representatives.

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