As healthcare consumes a significant portion of the US budget, oncology services similarly consume a significant portion of any hospital’s budget. The need to recruit qualified and wellpaid clinicians, the continuing medical arms race to ensure the hospital remains competitive by providing physicians and staff with the latest technical equipment, as well as the desire to satisfy increasing consumer demands for a reasonable clinical experience (eg, physician office wait times, navigation to traverse the physical confines of hospitals and their many facility add-ons, nontraditional treatment-hour extensions to enable individuals to continue working) all converge to ensure an active cancer program administrator is often in the position of requesting yet additional dollars to improve cancer care services, upgrade oncology equipment, or recruit new or additional specialized staff.

Although the term “benchmarking” is ubiquitous in quality-of-care literature, of immediate importance to cancer program administrators is their ongoing challenge with internal hospital competition for acquiring access to scarce or limited resources (eg, equipment dollars, capital budget funds). Because it is a highly technical field (often coupled with intense consumer/ patient/media scrutiny) without adequate funding, cancer programs may quickly fall behind and begin to bleed patient volume to competitors.

Program leaders often ask for accepted standards or benchmarks to establish a baseline need as they prepare a compelling (and successful) business case for whatever service extension, facility improvement, or staff recruitment challenge the program currently faces. Whereas certain benchmarks are well established, such as profitability, The Oncology Group queried participants on the Association of Cancer Executives (ACE) listserve regarding what other oncology-specific benchmarks or metrics experienced administrators found useful. An original survey was conducted in November 2007, and a similar survey was conducted in early 2010. Differences between the 2 years will be shown.

The survey

The survey asked respondents (the ACE listserve) to answer this series of open-ended questions.

As you work to position your cancer center within the confines of the larger hospital:

• What are the three to five most important benchmarks that you use to make your case for resources and support from senior administration; or which benchmarks does your administration require?
• What information/metrics/numbers do you need to sell the importance of oncology to your senior team?
• What metrics or resources do you use? Also, what has been successful?
• What metrics do you track and report on your oncology dashboard?
• And most importantly, what metrics have proven most useful to your team?
• If the hospital uses a balanced scorecard, what specific measures does your team use to track oncology services (eg, productivity standards for radiation therapy, departmentbased profit margin, cost-per-case, etc).

Survey findings

Seventeen experienced hospital cancer program administrators responded to the survey in 2007. Fourteen (82%) of the respondents represented large community hospital cancer programs. The remaining respondents (3; 18%) represented academic center cancer programs. In 2010, eight administrators responded, all from community hospitals.

Primacy of financial metrics

As expected, when reporting to senior administration, most respondents focused on financial metrics. Seventysix percent (13) in 2007 and 85% (7) in 2010 of the program administrators used some type of financial metric for reporting. Whereas some used a full service line financial metric, others used departmental measures as a surrogate. This is not uncommon, as many hospitals find it difficult to roll up the total financial impact cancer has on a hospital/health system (especially outpatient downstream revenue in pharmacy, radiology, surgery, and laboratory). In 2010, the trend was to use hospital-wide financials, which, in some cases, the respondents said “were not useful.” For example, financials were based on Medicare severity diagnosis-related groups (MS DRGs) and not ICD-9-CM codes or were for hospital inpatient only.

Table 1 lists financial measurements oncology program administrators reported they use and find useful to achieve their objectives with senior administration.

Patient volume also used by most

The next most common metric, patient volume, is relatively easy to measure and was used by 65% (11) of the respondents in 2007 and 100% of the 2010 respondents. However, it must be cautioned that using volume only may not provide an accurate picture of program growth. If the market is growing and your institution’s or cancer program’s volume is not keeping pace with that growth, the hospital (or the program) may be losing market share. Table 2 lists typical patient volume measures respondents reported using.

An interesting difference seen in 2010 was that half (4) of the hospitals monitored volume per physician (such as cases per medical oncologist; referralsto breast surgeon). This indicates that a growing number of cancer programs have closer alignment models (including employment) for cancer physicians than were evident in 2007. Volume and productivity measures are listed in Table 3.

More than half report using clinical quality guidelines

Just over half (53%; 9) of the respondents in 2007 and 25% (2) in 2010 reported using some clinical quality guidelines when preparing a business case. A number of programs used specific clinical quality guidelines and relied on numerous pages of quality measures and benchmarks, based on the American Society of Clinical Oncology’s Quality Oncology Practice Initiative, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology series, and other groups. Other programs reported using very few (ie, 1-5) clinical quality measures. Table 5 lists a sample of clinical quality metrics that several program leaders noted are of value to them and to their senior administrators.

Productivity benchmarks seen as valuable

More than one third (35%; 6) of respondents in 2007 and up to 62% of the 2010 respondents indicated reporting operational productivity statistics carried weight with hospital administrators. These metrics appeared most often to be monitored for radiation therapy departments. Table 4 lists examples of these benchmarks.

Patient satisfaction metrics important to some

More than one third (35%) of respondents in each year also noted that they used measurements of patient satisfaction to make their cases for additional resources. Most respondents did not list specific patient satisfaction measurements, though some noted they compared themselves with local results from Press Ganey data. A few respondents also noted that they used department-specific patient satisfaction scores as opposed to hospital-wide or cancer patient–specific surveys. Survey analysts assume these were tailored to the specific business case being made, or perhaps to what patient satisfaction tools or outcomes data were available in the institution.

Treatment volumes spell revenue

Surprisingly, less than one third (29%; 5) of respondents noted that they routinely used treatments per visit or types of treatment metrics in their operational or planning work in 2007. In 2010, that number was up significantly to 100%. Table 6 lists treatment-specific volumes some respondents report as useful.

Market share cited less often

Survey analysts are surprised also by the low importance apparently given to market share. Only three (18%) respondents noted that they used market share as an ongoing tracked metric in 2007. Analysts surmised this may be because inpatient market share data (although almost universally available) is such a poor measure of actual oncology patient volume, which is largely outpatient; or because local program administrators find it difficult to secure valid and reliable outpatient or analytic case market share data for their institution and certainly for competitors.

In 2010, this theory was supported, with respondents saying things such as “our hospital uses state-wide data for market share, but it is MS-DRG–based, which is not useful for the cancer program.” Others are utilizing cancer registry data for market share, but realize the limitation of timing for this measurement.

Time to treatment used rarely

One key patient dissatisfier is often time to treatment, defined as the time from diagnosis to definitive treatment. Two (12%) respondents indicated that they used a time to treatment benchmark as part of their operational evaluations in 2007; no respondent reported using this metric in 2010.

Remaining benchmarks

Respondents identified many other measurements they used in developing business cases or requests for resources. These included:

• Technology assessment based on the advisory board
• Number of individuals attending community events
• Grant or contract funding available for particular program elements.

An interesting finding seen in 2010 but not seen in 2007 was the number of respondents who stated that they measured the use of drug replacement programs to show money saved to justify support for that program. Just over one third (3) of the respondents reported measuring this metric.

Conclusions and discussion

These survey results, although informal and limited in their general use, do show that cancer program administrators use a vast array of indicators to support their requests for continued or increased funding. As working oncology program administrators recognize (but which fewer hospital administrators may know), cancer care often represents 10% to 15% of a general hospital’s revenue. Furthermore, cancer patients often provide the majority of vaunted patient volume for at least three key hospital departments—the operating room, diagnostic radiology, and laboratory/pathology.

Moreover, as reimbursement continues to be “rationalized,” an increasing number of supportive care or ancillary services targeted to cancer patients remain unfunded by the Centers for Medicare & Medicaid Services and other major insurers. These unreimbursed items include program elements such as patient navigation, nutrition counseling, financial counseling, support programs (support groups), and education. All these factors make it clear to program administrators that it is incumbent on them to continue to procure the funds necessary to care for individuals diagnosed with cancer who come to their institution for all, or most, of their care.

Procuring these funds typically requires the program administrator to “frame the cancer experience from the view of senior management,” as Catherine Harvey, RN, DrPH, AOCN, a leading cancer business consultant, puts it. This means coming to budget meetings armed with the facts that will tell your institution’s cancer care story in a compelling manner that covers both margin and mission.

About the Authors

Marsha Fountain, RN, MSN

President, The Oncology Group, Waco, Texas

Karen Gilden