Bringing world-class cancer care closer to home

Five years ago, if a cancer patient at Cooper University Health Care in Camden, N.J., had a complex case, the attending oncologist would review the medical literature and call colleagues to solicit input on the best course of treatment.

Now physicians can present challenging cases to a tumor board made up of experts in that particular form of cancer who come from Cooper and the University of Texas MD Anderson Cancer Center, one of the nation's top-ranked academic oncology centers. The two institutions formed the partnership in 2013.

“It's a very easy dialogue because we have this relationship,” said Dr. Generosa Grana, director of the MD Anderson Cancer Center at Cooper.

Cooper is among the growing number of hospital systems that are joining forces with renowned National Cancer Institute-designated centers such as MD Anderson based in Houston or Dana-Farber in Boston. Many regard these relationships as necessary to preserve quality and expand access to state-of-the-art oncology care. They also acknowledge that in an increasingly competitive market, association with a brand name oncology center helps attract patients.

“Folks are looking at ways to improve their position and access more patients,” said Jessica Turgon, who leads the oncology practice at ECG Management Consultants, where she is a principal. “There's a marketing element to all of this.”

But improving the quality of care is at the heart of the movement. “Community physicians get to leverage that knowledge base,” Turgon said. “It's good for everybody.”

About 1.7 million people a year are diagnosed with cancer, according to the National Cancer Institute. The cost of their care is projected to surge 25% from $125 billion in 2010 to $156 billion by 2020.

Cancer treatments are increasingly complex and tailored to the individual, and the best treatment must tap into medical advances that harness the power of genetics or the immune system. That highly specialized knowledge is usually found in the nation's pre-eminent cancer centers.

Yet patients increasingly desire to access their care closer to home where it is less expensive, which matters a lot as the price of cancer drugs skyrockets and an increasing number of patients are in high-deductible health insurance plans. When community hospitals join forces with the experts at cancer centers, they can tap those resources and expertise for patients with complex cases without having to send them away for more expensive treatment.

It also gives patients greater access to clinical trials that test experimental medicines. According to Dr. Stan Gerson, president of the Association of American Cancer Institutes and director of the Case Comprehensive Cancer Center, the proportion of patients involved in clinical trials ranges from about 2% to 3% in large community-based practice groups to 8% to 10% at most comprehensive cancer centers with the most highly specialized academic facilities enrolling as many as 20% of their patients in trials.

“That's a tenfold range of the opportunity for a patient to participate in a clinical trial, which is huge,” Gerson said. “We know that patients really do benefit from early-phase as well as late-phase clinical trials,” he added, although he cautioned against generalizations about the benefits of these trials for a disease as complex as cancer.

Comprehensive data showing the breadth and depth of these partnerships across the U.S. haven't been gathered yet. Gerson said the AACI is developing a survey of its 95 members to determine how partnerships have changed in nature and number in recent years.

Every oncology partnership is a little different.

Rochester, Minn.-based Mayo Clinic has a care network, not geared specifically toward cancer but through which members can still access oncology specialists and eTumor Board Conferences, among other clinical resources. New York-based Memorial Sloan Kettering Cancer Center also has an alliance that dates back to 2014 and so far includes two members.

Dana-Farber Cancer Institute's collaborations run the gamut from integrated care at local campuses to satellite clinics operated in partnership with community hospitals. It also has formed affiliations with hospitals outside the Boston area. The latter category includes assessments, consulting services, educational opportunities and access to some clinical trials.

Dana-Farber's mission is to improve local care and disseminate research findings, said Elizabeth Liebow, the institute's senior vice president for business development. “It makes a big difference to patients to get care close to home.”

When Berkshire Medical Center's Cancer Center in western Massachusetts partnered with Boston-based Dana-Farber/Brigham and Women's Cancer Center in September 2015, the objective was “to validate and ensure we provide really high quality care,” said David Phelps, CEO of Berkshire Health Systems, based in Pittsfield, Mass.

A team from Dana-Farber spent a week studying Berkshire's cancer center, including examining its written policies and observing its care. Dana-Farber recommended almost no changes, according to Phelps, but it continues to annually assess Berkshire's program.

A lot of Berkshire's patients still travel to Dana-Farber in Boston for second opinions after they are diagnosed with cancer. Because Berkshire does not treat rare cancers or conduct high-end surgeries, patients still typically travel to Dana-Farber for those procedures too, Phelps said.

“We wanted a relationship that would allow our clinicians and providers to maintain their knowledge and education,” he said.

MD Anderson's network, meanwhile, offers “certified membership,” which is a quality-improvement and best-practices program. It also has fully integrated “partner members” such as Cooper and Scripps Health in San Diego, as well as “associate members,” which are its international partners.

Scripps is one of its newest partners. They announced the collaboration in August, but work started well before that. A team from MD Anderson spent six months at Scripps, vetting its cancer program.

“They came back and said if you were part of us, we'd have certain expectations to change your cancer program and work in a much more integrated way,” said Chris Van Gorder, Scripps' CEO. Over the next year, Scripps will change close to 100 different standards to comply with MD Anderson's standards of care.

Those revisions touch care pathways, patient protocols and clinical research. Scripps will also gain access to MD Anderson's specialists, the thousand clinical trials it runs at any given time, and tumor boards.

“MD Anderson has 21,000 people focused just on cancer. I have 15,000 people focused on everything,” Van Gorder said. “We think by following MD Anderson's protocols—and they're constantly changing those protocols based on the latest research—our clinical care will improve.”

At Cooper, partnering with MD Anderson led to substantial changes, some of them challenging.

“We've had to counter decisions we've made in the past,” said Adrienne Kirby, Cooper's CEO. Prior to the partnership, Cooper intended to use a certain documentation system for medical oncology. But MD Anderson used a different one, so Cooper had to scrap the original plan and forgo its initial financial investment.

Cooper also had to put several millions of dollars into upgrading its pharmacy to meet MD Anderson's standards. “Not everyone has the stomach for that level of protocol-ization of care,” Kirby said, although “that was exactly what we wanted.”

Partnering with a name-brand institution is also a boon to hospitals' bottom lines.

After Cooper partnered with MD Anderson in October 2013, revenue for the cancer center rose 22% the next year and 18% from 2014 to 2015, according to Kirby. “It's been a very significant impact for us from a financial perspective,” she said. Patient volume has risen 20%, she added.

As a university health system, located across the river from Philadelphia, Cooper is “really competing in name-brand recognition for higher-end cancer care, and cancer care in general,” Kirby said. “We're in a very cluttered market, where there's some big gorillas across the bridge.”

In this environment, partnering with a facility of national repute such as MD Anderson gives Cooper a competitive edge in attracting patients. Grana, the oncologist, said the relationship has also helped the hospital lure top talent among nurses, doctors and leaders.

Kirby said Cooper's ultimate goal is improving quality of care. “It seems counterintuitive to partner with a provider located in Texas,” especially when Cooper could have selected a center closer to home, she said. “We just didn't want a superficial partnership. ... We wanted to really change, influence the care we delivered to patients.”

And they have. Use of tumor boards, which are associated with better outcomes for patients; additional patient navigators and advanced practice nurses; and greater reliance on the molecular and genetic aspects of care are a few of the transformations the center has made.

The decision appears to be paying off in terms of outcomes. Cooper's MD Anderson Cancer Center has a

0.36 observed-to-expected mortality rate, according to Kirby. This ratio means that its actual mortality rate is 64% lower than expected.

Profit and quality of care don't have to be inherently contradictory, some say. “There's this push toward high value, high quality,” said Turgon of ECG Management Consultants. At the same time, physicians are asking, “What is the personalization of care that I need to afford my patient, given their indication, and how do I understand that?”

But when brand names serve as differentiators in highly competitive markets, “there's a lot of marketing dollars being spent on communicating the benefits of these programs,” she said. “Could you spend that marketing dollar on something else for that patient?”