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Key #2: Match technology to mission
Technology isn't the differentiator for oncology programs that it once was. Specialized radiation therapy technology is fairly ubiquitous, even in smaller rural hospitals with cancer programs. But that doesn't mean technology doesn't matter—multimillion-dollar purchasing decisions can't be taken lightly.
Technology is perhaps the biggest differentiator in subspecialty, site-specific cancer programs. Want a reputable neuro-oncology program? That's tough to pull off without stereotactic radiation therapy, a gamma knife, and other specialized radiation therapy technologies that specialists need.
So the cost-benefit of a particular piece of equipment will vary from hospital to hospital, depending on whether it advances a high-priority subspecialty focus for the program. "You need to match the technology to the program's mission," says Comish.
Comish has heard of hospitals in rural areas proposing to purchase technologies that statistically couldn't generate more than five or 10 uses in a year. "That is clearly not a warranted investment and may point to quality concerns if not routinely performing those procedures and maintaining proficiency."
Key #3: Partners close, competitors closer
Because cancer care is such a team-based enterprise, getting physicians and other team members to buy in to the overall mission and success of the program has a big impact on its overall efficiency and efficacy. But there's no one-size-fits-all approach in oncology service lines.
Trinitas Medical Center employs its medical oncologists, but the radiation oncologists are in private practice with an exclusive agreement to provide professional services. "That's fairly typical of what you see at other hospitals. It has to do with the economics of the two professions," says Emery.
For the most part, Trinitas works to build close ties with primary care physicians and other potential referrers, relying on physician-to-physician relationships, as well as education and training programs, to build professional trust.
"We visit a lot of doctors to talk about services and to educate them on what we have and why it's important. We go out once a week on average to an outside physician office with one of our doctors, and we have an educational presentation about the program and services we have here. It gives us an opportunity to educate them and get to know them better and how we can better satisfy their needs."
But then there are the potential competitor physicians, who require a different approach. In recent years physicians who have traditionally held the referrer role have been skimming some of the radiation oncology business away from hospitals and cancer centers. A group of urologists, for example, might purchase a linear accelerator and hire a radiation oncologist, and instead of referring a patient with prostate cancer to the local hospital, they can now treat it in-house and recognize a new revenue stream.
"These facilities continue to open and are detrimental to the multidisciplinary model of patient care, in which patients are evaluated by physician specialists, who can be objective in their decision making. If you look at just prostate cancer cases, those patients are gone almost over night," says Emery.
In some cases, the hospital and physicians end up as fierce competitors, or the hospital simply has to concede a portion of the business. But the competition is one factor leading some hospitals to employ specialists, in an attempt to force alignment between the two parties.
The overall impact varies by market, depending on factors such as state certificate of need requirements and other market dynamics. There is a lot of disagreement over whether physicians should even be legally allowed to own and operate certain types of radiation therapy equipment, and the competition extends into political and legal arenas, as well.
Key #4: Build a cancer center
To build or not to build? Like many service lines, oncology has seen growth in outpatient centers that serve to centralize services and distinguish cancer care from the rest of the general hospital services. Although these are expensive, cumbersome projects, the payoff is convenience for both patients and physicians.
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