Many community cancer centers desire to offer prospective multidisciplinary case conferences for their patients. However, various business models can be set up to achieve this goal. In this interview, Nancy Harris, administrator of St. Joseph Hospital, The Center for Cancer Prevention and Treatment in Orange, California, discusses how her community center established relationships with its providers, all of whom are in private practice. Along the way, she notes some practical concerns for other administrators looking to use a similar practice model.

What type of practice model does The Center for Cancer Prevention and Treatment use?

It is very much a cooperative relationship. We call the structure to this relationship “conditions of participation.” This terminology came up when we were looking for a way to structure what we could provide to physicians who were participatory, those who were giving their time and expertise in a voluntary capacity. We wanted to structure it in a way that made it clear that what we offered would set these physicians apart. We looked for what we could give them back.

In crafting the conditions, what incentives do you offer physicians?

We offer them support for research. Our staff puts new studies through the institutional review board, our staff does all the data management, and our staff does all the contracting. In addition, we have a budget for when the physicians take histories and perform physicals; when they do work related to the research they are reimbursed. This gives our physicians the advantage of being able to offer their patients national studies without incurring the overhead and the work.

We also involve the physicians in decision making when it comes to technology and equipment. For example, we just selected a new cancer electronic health record (EHR) system. The physicians were very much a part of the decision making and requirement setting for what capabilities needed to be included in the EHR.

That was significant, not only in the respect that it was selecting what would go on in the cancer center but also in the respect that full participants would have priority in gaining access to that EHR in their offices. In addition, we are negotiating a very favorable financial arrangement so that it is easy for them to implement the EHR and meet the meaningful use requirement in the American Recovery and Reinvestment Act.

Physicians who are full participants are featured on our website. We found that our physicians like being connected with the center. Because we promote our website quite a bit, they see it as an opportunity to be highlighted.

We also offer physicians opportunities to participate in community events and physician education events. Plus, we support all the cancer conferences— more than 20 per month. Our staff reports all of our physicians’ cancer cases to our cancer registry.

Our staff also takes care of the state-mandated requirement for cancer reporting. In addition, we track and manage many of the outcomes through our American College of Surgeon’s Commission on Cancer registry. Many have some special outcomes that they want to track in addition to survival, and we keep those up.

The other thing that we do is we provide some nurse support. The center has nurse navigators who support these physicians as well as act as a safety net or additional co ordinator for patients. For example, perhaps a patient had a clinical consultation and didn’t quite understand it. That patient will go to the navigator and ask what it all means or to put it into perspective. The nurse navigators work directly for the center, not any one physician.

What do you expect the physicians to give back to the center?

Our physicians are expected to be present at at least half of the cancer conferences. Our program is structured into site-specific teams. We have a breast team, a colorectal team, a urologic oncology team, a melanoma team, a head and neck team, and a liver tumor team. For some of the sitespecific teams, there is a core set of expectations on the hospital side as well as on the physician side, and there are some team-designed additions. For example, the lung team wants to see suspicious nodules within 48 hours. The genetics team has asked for a specific requirement regarding training for their members. A variety of things can be added to make the conditions of participation unique to each site-specific team.

Physicians also need to be timely in terms of when they see referred patients. We expect that they will see these patients within 1 week, that they will provide verbal consults with the referring physicians within the same business day, that they will provide second opinions, and that they will maintain communication with the primary care or referring physician. We also expect the physicians to participate in a very active way with our nurse navigators. In addition, we started a breast clinic for underserved women, at which physicians are expected to provide care on a rotational basis, knowing full well that the reimbursement will not be very good.

Physicians need to be board-certified and maintain their medical staff membership. They must participate in local, regional, and national organizations to maintain professional expertise. Physicians also must support us in publications and presentations at regional and national conferences.

One of the biggest things we expect from our physicians is data. Physicians have to share their data so that we can generate outcomes, track outcomes, and publish outcomes. We also use these data to determine where we stand and where there are opportunities for improvement, and to know where we do very well, which we like to make known. This includes things like participation in the American Society for Clinical Oncology’s Quality Oncology Practice Initiative, registry data, and, if we are doing a special study, the outcomes. We have done numerous special studies and have found that the physicians truly get engaged in the outcomes. They are as interested as we are in producing them. Physicians also participate in patient-satisfaction activities. We use those data to ensure that not only are we doing all the clinical things but also the satisfiers that are important to our patients and their families.

We also require that the physicians participate in research. Part of this is going through the organizational mandate of city training. They cannot become a subinvestigator until they complete that training.

In developing your business model, did the center approach physicians or did physicians approach the center?

The decision to design a new business model began when some of our physicians noticed the difference between the care some physicians gave compared with others. Because community physicians chose their referral patterns and because hospital-participating physicians had access to hospital resources, those who participated heavily wanted there to be a recognizable distinction. At the same time, the hospital wanted to structure something for recognition purposes. The hospital wanted to create those boundaries that are recognized legally as these individuals are giving and we are returning support in like quantities, that is, fair market value.

What research did you perform when developing your conditions of participation?

We did some searches, both formally and informally, and some networking among colleagues. I spoke with Pat Grusenmeyer, past president of the Association of Cancer Executives and senior vice president of Christiana Care Health System, about conditions of participation. Christiana Care had just taken that step and published an article on it. We accessed that information, and then vetted it through a number of our physician leaders to see their responses.

The key was to look at things that were sustainable, and doable, and had value for both parties. Another important component was that we invited the whole medical staff to choose whether they were going to opt in or out. Someone was not choosing for them. It was them making that choice for themselves. With that, it is not the hospital using a stick or anything. It is “here are our expectations, can you meet them or not; is this of interest?”

What follow-up measures did you build into the system to ensure both parties meet expectations?

We always track who is at cancer conferences. The registry is also tracked as far as who shares data. We have not met resistance. Sometimes it is cumbersome, sometimes it is time-consuming. It turns out that for the physicians were so participatory in the selection of our cancer EHR, it is not a matter of will they participate or will they share their data. It is a matter of how fast can they get it done. When they are part of the solution and they are part of making the center better and they truly have roles, there is a very different feel. It is truly much more of a partnership.

Were there any significant challenges you had to overcome?

The biggest challenge is actually the tracking. Also, medical oncologists often view themselves as generalists, that is, they can do all cancers. The fact of the matter is that for the level of participation we are looking for as well as for just keeping up with all the data that are generated, it was very hard for some, because they want to do everything and they overwork themselves going to all the conferences to meet the participation requirements. We now are asking them to choose their passion. We want them to choose the conferences that appeal to them because when they come to the conferences, the expectation is that they will contribute, they will be an active member of the team with respect to research, presentations, and outcomes. We expect them to generate referrals among their colleagues who see them doing all this participation and sharing knowledge.

Is there anything you would recommend to physicians who wish to get involved in a program like yours?

If they are looking to find common ground and quality is of concern and if they want to do outcomes work and they want research support, I think this mechanism is one that truly supports private practice physicians and creates a nonlegal relationship with a cancer center where expectations are clear. For the centers that chose to go down this path and the physicians who chose to participate at this level, I think this is how they can get the harmony and the quality patient care. Everyone is on the same page as far as this is the best for patient outcomes and this is the best as far as the clinical outcomes. It is agreement on that vision.