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VBCC - February 2012, Volume 3, No 1 - Best Practices

Ventura County Hematology Oncology Specialists has so far managed to avoid many of the financial difficulties facing a large number of community cancer practices. Value-Based Cancer Care asked Dr Parsa and Ms Rivera to discuss what makes their practice successful from a clinical and a business perspective.

VBCC: When was the practice established, and what are some of the services you offer?

Dr Parsa: I was the first medical oncologist in the western Ventura County area when I started the practice in 1971. Rosemary McIntyre, MD, joined me in 1980, and by the time the third physician joined us we were operating in 2 sites—Oxnard and Ventura. When our sixth physician joined in 2008, we opened our third site, in Camarillo. Currently we have 7 physicians, who are all hematologists-oncologists. In addition, we have 1 physician assistant and 10 nurses working in the 3 sites.

In late 2010, the Ventura site expanded its infusion capacity, and in mid-2011 the Camarillo site began to provide infusions. Currently all 3 offices provide infusion services. The 3 offices are located within 8 miles of each other. We serve a very large population of about 700,000 people in Ventura County, which encompasses many cities, including Santa Paula, Fillmore, Ojai, Port Hueneme, Somis, Ventura, Oxnard, and Camarillo, as well as the Thousand Oaks and Simi Valley areas.

We also have a pharmacy technician who dispenses oral medications in-house, a licensed clinical laboratory scientist to oversee laboratory services in-house, and full-time research services that allow us to enroll patients in National Cancer Institute–approved clinical trials so patients do not have to go to university centers in Los Angeles, which is about 50 miles south. These enhance our patient care and ensure that we can offer patients important services within the context of our practice.

Ms Rivera: We have been using an oncology-specific electronic medical record (EMR) system since 2006 and started prescribing electronically (e-prescribing) in 2009. These are important features to have in any oncology practice. Being efficient is very important to us, because it is directly related to our ability to survive economically as a practice. Our hope is that our EMR system will help us be even more ef­ficient, so we could concentrate our efforts on improving patient care.

Each of our 3 sites is located either in the hospital’s medical office building, or in close proximity to the hospital. Although not part of our practice, radiation and imaging services are available in the same facilities at our Oxnard and Ventura sites. Patients who need radiation and chemotherapy can have these done on the same day, in the same building. It is very convenient to our patients.

VBCC: Why do you need 3 separate infusion centers in such close proximity?

Ms Rivera: The 3 sites serve very different demographics. Our Ventura center covers the neighboring cities. We expanded our infusion center in late 2010 to accommodate the demand. This makes it very convenient to these patients rather than traveling to Oxnard. The Oxnard center is in the middle, and it serves the largest population. Camarillo has many senior residents, who often prefer to see physicians and be treated within the city limits. Offering infusions close to people’s homes is an important feature of our practice. Having 3 smaller infusion centers rather than a large one gives them a noninstitutional, neighborhood feel. We are also lucky to have very skilled and compassionate oncology nurses. Our patients love them.

In fact, there are other physician specialists, such as rheumatologists, from Ventura County, who send their patients to us for infusion. This service also generates additional revenue.

VBCC: You mentioned that you are involved in research. Could you elaborate on this?

Dr Parsa: We have a full-time re­search coordinator, and we are continuously involved in approximately 10 or 20 clinical trials at one time. In the past we were associated with the University of California, Los Angeles, for clinical trials, but this involved a long drive for patients.

Once we switched to US Oncology, we are now able to provide all the research coordination directly at our practice. Having such a large population of patients allowed us to coordinate the research with US Oncology. Our patients like being able to join a trial directly through our office.

Approximately 10% of our patients participate in clinical trials. Our research coordinator informs us during our weekly meetings which trials are open, and we coordinate this based on the type of patients we have. The research coordinator then matches the patients with the trials, and if the patients agree, they are being signed up.

VBCC: What are your main financial concerns?

Ms Rivera: Our single largest expense is drugs. One main concern is not recovering the cost of purchasing, administering, and billing for the drugs. It is also difficult to get reimbursed for many drugs, considering how expensive cancer drugs are. Certain insurance companies require a long turnaround time for prior authorizations, which often makes the treatment process very inefficient.

Many patients are also not fully insured, and some employers have been opting for lower-premium, higher out-of-pocket cost plans. Our group cannot sustain a practice when patients are unable to afford their share of the treatment costs that are not reimbursed by their insurance. This is why we have staff members who find help for patients through foundations and manufacturers’ copay assistance programs. We find financial help for patients so that they can afford their cancer therapy.

Patients are treated with generics when these are available and are equivalent in efficacy. As overhead costs continue to rise and with reimbursement going in the other direction, we strive to be as efficient as possible to stay in business for our patients in the community.

Through the help of Community Oncology Alliance, I am also active in advocacy efforts to educate members of Congress about the current crisis in cancer care access. Our Congress members need to understand that keeping cancer care delivery in the community setting costs the system less.

VBCC: Many community cancer centers today are struggling with economic issues and competition from neighboring hospitals. Are you worried about this? 

Dr Parsa: We are not experiencing these issues yet; we are still doing fairly well. Many of our patients have insurance, and we keep close contact with the primary care physicians in the area, who are very satisfied with us and keep referring patients to us, once a cancer diagnosis is made. Approx­imately 90% of the patients we have come to us after an initial cancer diagnosis was made or suggested.

Although there are 3 hospitals in the area, and the county hospital has its own oncologist, we are the major community practice in the area offering hematology oncology services. We have approximately 500 or 600 pa­tients under our care on an ongoing basis, and the majority of them come from our area physicians.

Because we are the main oncology practice in our area, we get the majority of the patients from the primary care physicians in the area. Therefore, the area hospitals do not present a threat at this point. Having a strong connection with the area physicians is crucial and is probably the main reason for our success. In addition, we run an excellent business office under the leadership of our business manager, Marissa. She handles all the business decisions.

Ms Rivera: We are aware that last year 199 community cancer centers closed or were sold to hospitals. Even here, in Southern California, I see a growing trend. Oncologists are tired of taking the risk of fronting the cost of drugs without the certainty of getting reimbursed properly. So far we are in a different situation. Our group has the biggest presence in western Ventura County. Our physicians played a major role in developing cancer programs in our area in conjunction with the community hospitals. We are an integral part of the community and the major provider of cancer care in our area.

Every year our physicians provide free talks to the public regarding cancer prevention. They have touched on genetic disposition as well. Recently, they have expanded the talks to discuss available cancer treatments and the importance of follow-up after active treatment is over.

Obviously, we have to be financially viable to be able to offer oncology services. As the business manager, I believe that our physicians should focus on providing the best cancer care to patients. That is why I focus on running an efficient office—to free the physicians to focus on the clinical aspects of the practice.

VBCC: Can you discuss some of the business aspects of running a successful cancer practice today?

Ms Rivera: We are all doing more these days. To survive, we have to maintain a very lean staff, and we all have to do our part. The following points represent the main aspects of our success:

  1. We have the biggest presence in the area, which is an important factor in our success. Our flexibility and adaptability to changing times also allow us to survive.
     
  2. Another important factor is efficiency. We are running a very efficient practice. We run a lean staff and are not “top heavy.” Everyone is now doing more, including the physicians. Some responsibilities, which probably could be performed by medical assistants, are being done by our physicians. We expect everyone—the physicians, the nurses, the billing office, the laboratory, the back and the front offices—to do their part, as costs continue to rise and reimbursement continues to be “flat,” or even go down.
     
  3. Another example is that those working in the front office know how important it is to collect the copayments upfront, so we do not have to waste time on collecting it later. Or, if patients do not have full coverage, we help them get money from different foundations to pay for their bills. This way, we help them pay their bills, and we help ourselves to get paid for our services. We do not just leave it to patients to figure it out on their own.
     
  4. We have been participating in the Physician Quality Reporting Initi­ative (PQRI) since 2007. We have been successful every year in reporting the PQRI quality measurements to the Centers for Medicare & Medicaid Services (CMS). Each year we select quality measures to report on, and we report them to CMS. This means we have been getting the bonuses from CMS for the past several years, which helps financially.
     
  5. We have also met the requirements for e-prescribing since this program was instituted by CMS. We have been encouraging the physicians to do e-prescribing. We participate in all the programs that offer incentives by CMS, and we have been doing this for many years. We participated in past demonstration projects by CMS. The business aspect of a practice is very important to the success of the practice. We do not take anything for granted, and we realize how important it is to take advantage of such programs.
     
  6. This year, we plan on attesting for the EHR (electronic health record) Meaningful Use Incentive Program. Successful attestation gives each physician the opportunity to receive a bonus totaling $44,000 payable in 5 years.
     
  7. This is also true about technology. We use technology to improveour efficiency. The EMR system, for example, is very important, especially be­cause we have more than 1 location. Having paper charts is not efficient, and it can interfere with providing the best care for patients. If the chart is in one office, and the nurses need it in the other office, this is not efficient.

    Moving to EMRs was very important to improve our efficiency. Now everyone has access to the patient’s medical record regardless of office location. We also use technology to automate certain processes for our practice management system, which also allows us to manage with a smaller staff at a high productivity level.
     
  8. Billing is also part of our EMR. When nurses enter the start and stop times for each drug, the EMR knows which Current Procedural Terminology (CPT) codes to bill. Our billing specialist imports the physician and treatment charges electronically through an interface instead of manually entering them in our practice management system. Before submitting claims, we use claim edit software to make sure that all the diagnoses, CPT, and Healthcare Common Procedure Coding System codes needed are not missed, because it is more efficient to send the claims when they are correct and clean than to fix them later. Going through hundreds of claim lines daily is taxing for a person, but technology assists to ensure that the claims are correct before submitting them. We send claims every day. Some practices wait and submit claims once a week or every 2 weeks, but we process and submit claims every day.
     
  9. Our physicians meet every week to discuss clinical cases. In addition, we have a business meeting every month. Keeping the communication open between the physicians and the business administrator is very important.
     
  10. As one of our physicians, Ann Kelley, MD, commented, the secret to our practice’s success is excellent office management with fiscal discipline, experienced and dedicated nurses and staff, caring physicians, rare turnover, and above all—great team work.

    I believe these are some of the main reasons that we are able to survive as a practice.

VBCC: Finally, you have mentioned that you have patient education programs. Can you elaborate?

Ms Rivera: We provide support programs for patients and the community. Our physicians are very active in educational and support programs in the community. For example, one physician is always attending the prostate cancer support group. Because we have a big presence in the community, when any organization, such as the American Cancer Society or one of the community hospitals has an event for the public regarding cancer, one of our physicians usually speaks at that event.

Recently we hosted and sponsored our own series of educational events for the community. We had a series of talks related to breast and prostate cancers. Topics include risk factors, prevention, early detection, treatments available, and what to do after treatment. Many of the people who attend these meetings are not necessarily our patients but rather people from the community who are interested in the topic. The goal is to keep the community informed about cancer prevention and treatments, and of course these are free events. We plan on hosting more educational community events for other types of cancer.

In addition, we provide a symposium about once every other year to physicians in the area—such as surgeons, gastroenterologists, dermatologists, urologists, pulmonologists, neurologists, cardiologists, hospitalists, nephrologists, gynecologists, and the primary care physicians in the community...to educate them on the latest advances in cancer care. Our community cancer practice is truly an important part of our community at large.

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