The American Cancer Society estimates that more than 1.6 million Americans will be diagnosed with cancer in 2016. The majority of these patients will be treated in the community hospital setting, receiving care from a wide array of physician specialists. As more hospitals have joined or formed health systems in recent years, coordinating care for these patients has become tremendously more complex.
The complexity of organizing a “systems” approach to care is not unique to oncology, but unlike most service lines, oncology does not have a well-established position in health care planning and management. Many leaders have been unable or uninterested in organizing a service that spans nearly all inpatient and outpatient departments and a wide array of employed and unaligned specialists. In addition, the economics of cancer are unfamiliar to many in health care.
Centralizing the governance and program development of cancer care can be difficult in a single institution and overwhelming in a systemwide network approach. But despite these challenges, many health care systems have successfully created programs that are more substantial than the sum of their parts.
Designing an architecture
Successful network building starts with a thoughtful and sequenced plan. Health systems too often jump straight to implementation — deciding which surgical oncologist needs to be recruited, how many linear accelerators need to be purchased, which cancer network accreditations need to be pursued. These more glamorous stages of delivery design are necessary but should not bypass the planning phase or development of a business architecture for an oncology network.
Determining a business architecture starts by defining an appropriate network model. In some organizations, this architecture will mean a hub-and-spoke system, in which a tertiary and quaternary cancer program handles high-end management of rare and complex tumors while facilities closer to home treat simpler breast, thoracic, prostate and colorectal cancers. In other organizations, the appropriate model may be a distributed architecture, with standard capabilities available at a number of sites, potentially integrated with a cancer center designated by the National Cancer Institute or an academic partner.
It is important that the resulting architecture is informed by the market landscape, geographic proximity of sites, and the specific demographics and needs of the cancer patient population. For example, cancer diagnoses skew toward an older population and may require biweekly chemotherapy or daily radiation therapy, limiting the mobility of patients. The organization should consider such factors in its network design.
The business architecture and network model should influence the leadership structure of the service line. System-level governance may best be managed with an effective oncology advisory council, including representatives from the C-suite at each hospital as well as physician champions from key tumor site services (e.g., breast surgery, thoracic surgery, and medical and radiation oncology). This group can be tasked with driving the vision and strategic plan for the service line, creating participation requirements for physicians and resolving the inevitable conflicts of interest that arise as the delivery network is reorganized.
It is also vital that the service line leaders, both administrative and medical, have executive authority (from a system vice president or CEO sponsorship) or direct authority over governance, as in a CEO or institute model. Leaders must also have access to a service line global budget that captures the full contribution of cancer services in the diagnostics, surgery, infusion, radiation therapy and outpatient ancillary departments at all hospitals in the network. This “virtual” ledger becomes a valuable tool in assessing incentive alignment, managing performance of the service, and building the necessary case for programmatic and capital investment.
Sequencing for success
Once the business architecture is in place, there should be a staged implementation. To start, the oncology advisory council should make key decisions about the tactical implementation that needs to occur at the system level — versus what will occur at the individual cancer program level.
The council should also play a vital role in staging the rollout of oncology “systemization” of shared services that benefit most from a standardized approach. In cancer care, this systemization includes:
- Using shared purchasing power for expensive chemotherapy drugs and radiation therapy equipment.
- Standardizing oncology information systems such as oncology electronic health records, a data warehouse or a tumor registry platform.
- Consolidating resources used for clinical trial management.
- Developing streamlined patient support programs for navigation, psychosocial needs, rehabilitation and survivorship.
The next step of network development is creating oncology clinical performance groups with representatives from the network. These groups should be tasked with performing comprehensive gap analyses of their respective tumor sites and providing a road map for system-level integration. That road map typically includes developing standardized clinical pathways, tracking key quality performance indicators, and identifying the disease-specific resources and capabilities needed for program development. These groups allow for sharing of best practices throughout the network and create the sense of there being one cancer program at all delivery sites.
The final phase of oncology network implementation capitalizes on the true merit of consolidation: providing a greater value to the consumers of cancer care — patients, payers and employers. Integrated systems with shared purchasing, standardized care, common information technology platforms and so forth can design and promote a true value-based cancer product. These systems can leverage scale to provide screening and prevention efforts for the at-risk population and offer access to cutting-edge clinical trials when treatment is needed.
Leading oncology networks are also entering into oncology shared-savings models with the Centers for Medicare & Medicaid Services’ Oncology Care Model as well as Blue Cross systems in New Jersey and Florida and are piloting payment bundling for entire episodes of cancer care. Integration is enabling these networks to rethink how and where care is delivered; create tumor-specific centers of excellence; redirect care to high-volume or high-quality providers; design sophisticated tumor site cost accounting; and optimize patient access, outcomes transparency and the care experience.
Organizing cancer care in a health system can be vastly complex. But for those organizations willing to follow a disciplined process, guided by a broadly endorsed vision and business architecture, the results can be profound. Successful oncology systems integration has a proven impact on improving care for patients, expanding access and experience, and enhancing the cancer ecosystem’s ability to succeed in a value-based world.
Ryan Langdale, MBA, is a partner with Oncology Solutions in Decatur, Ga.