Tennessee Oncology Group Finds Growth Bonanza in Clinical Trials

F. Anthony Greco, MD, Tennessee Oncology

F. Anthony Greco, MD

Tennessee Oncology was a relatively small practice until 1992, which is when F. Anthony Greco, MD, left Vanderbilt University Medical Center to become its fourth partner. Greco came with the then-radical idea that he could perform more trial work at a private practice than he could at a larger institution, such as an academic hospital. His vision not only made Tennessee Oncology a key player in many oncology studies, but also precipitated its 25 years of rapid growth.

By 1996, Tennessee Oncology had hired its 15th physician, current CEO Jeffrey Patton, MD. Today, after a trio of mergers and sustained organic growth, the practice has 81 physicians who provide care in 30 locations in central and east Tennessee. This growth has made Tennessee Oncology the dominant provider of cancer care across its service footprint. It has also fulfilled Greco’s original vision: Tennessee Oncology does significantly more work on clinical trials than the only big competitor it still faces, Vanderbilt Ingram Cancer Center.

“We have more patients in clinical trials than any other private practice in the country, and when you look specifically at phase I trials, we’re the second busiest drug development unit anywhere in the world. We have been the venue for more than 100 first-inman trials,” said Patton. “We are very proud of this trial work, both because it gives our patients options that they could not get elsewhere and because it advances the state of cancer care for patients all around the world.”

Tennessee Oncology conducts this work across an extremely varied service area. It is based in Nashville, a middle-income state capital of just over 650,000 people that lies at the heart of a booming metropolitan region with 1.8 million inhabitants. The practice’s footprint spreads far beyond that region, however, across more than a dozen rural counties, all the way to Chattanooga, a middle-income city of 175,000 just north of the Georgia border. Cancer incidence rates exceed the national average throughout most of this region.¹ State officials report that Tennessee ranks 19th nationally in per capita cancer incidence and third in per capita cancer deaths.²

Many factors contribute to this problem, especially tobacco use. About 22% of Tennesseans³ (compared with only 15% of Americans⁴ ) smoke cigarettes, according to the Centers for Disease Control and Prevention. As a result, Tennessee’s annual lung cancer death rate of 56 per 100,000 individuals far exceeds the national average of 43 per 100,000.⁵ The exact size of the problem varies greatly across Tennessee Oncology’s service area. In the wealthy suburbs of Williamson County, the lung cancer death rate is just 41 per 100,000, but many other health metrics exceed national averages. In rural Polk County, the annual lung cancer death rate of 103 per 100,000⁶ is just one of many serious public health problems.

“Different parts of our service area differ in just about every way you can imagine, but our operations are the same pretty much everywhere, except that offices are smaller in less populous areas and some of them operate fewer days per week,” said CFO Ron Horowitz. “Despite the overall demographics of a particular area, you get all sorts of patients at every office, so you have to be able to deal with different cancers and different financial situations and different everything at every office.”

The real challenge in covering Tennessee Oncology’s service area isn’t so much the differences from place to place as it is managing the growth of the practice. “When you’re growing from a local to a regional practice, you have to be careful not to outrun your support,” Horowitz said. “It’s easy for technology to give the impression you can open an office anywhere you can get an Internet connection, but oncology requires physical support. If you have an office that’s 200 miles away from any other office, you can’t get staff there to cover unexpected absences or medicine when your refrigerator breaks. Offices need to be close enough to support each other when the need arises. Otherwise, you don’t get the benefit of running a network rather than a series of independent offices.”

Although primary care providers, public health officials, and others probably have more ability to reduce the state’s elevated cancer incidence rates and get patients with cancer diagnosed earlier, Tennessee Oncology is continuously testing new strategies for improving outcomes once patients are diagnosed. The practice’s ongoing participation in clinical trials is an example, but the group has also spent the past few years testing new care delivery models and gradually implementing them across its practice.

Tennessee Oncology now uses Via Oncology’s treatment pathways software to help determine how to treat most of its patients. This technology ensures that its oncologists know the accepted standard of care for patients with a particular diagnosis and that the overwhelming majority of patients with that diagnosis receive the specified treatment regimen. Some oncologists at the practice have resented the loss of autonomy, but Patton says there’s more than enough evidence to support pathway adherence in about 80% of all cases (with usual factors justifying deviations in the remaining 20%).

“We all have a very natural and understandable tendency to want to treat patients on a truly individual basis, based upon each patient’s unique attributes and our own unique experience of what has and hasn’t worked in the past,” Patton said. “Unfortunately, there’s a mountain of evidence showing that a standardized template outperforms individual discretion for a large majority of patients. Medicine, it turns out, is a lot more like manufacturing than many of us like to think. If you do something exactly the same every time, you produce better outcomes and make fewer mistakes than someone who does it differently every time.”

Tennessee Oncology has also tested an oncology medical home (OMH) model of service delivery. The goal of all such models is to improve patient outcomes while simultaneously reducing the total cost of their care, mostly by offering patients so much extra access to oncology care that little problems never get big enough to send them to the hospital. Typical provisions include 24/7 telephone triage to encourage same-day appointments when problems arise.

The pilot program provided Tennessee Oncology more than a year to work its way through all the issues associated with the transition from a standard care model to the OMH in order to develop new workflows and work out any kinks that arose. The practice was therefore ready last summer to roll out the new service model to all patients covered by CMS when that organization launched its Oncology Care Model (OCM). CMS has been collecting data on costs and outcomes for more than 6 months now, but the agency has yet to report back to Tennessee Oncology on whether its OMH model is reducing hospital usage. (Tennessee Oncology has no access to hospital records and thus could not evaluate the OMH program’s efficacy during the pilot.)

The practice also provides OMH care to patients insured by Aetna, which has embraced the model. BlueCross Blue Shield, by far the largest private payer in central Tennessee, and Cigna, the second largest private payer, have not yet expressed any interest in covering OMH services or experimenting with any sort of outcome-based payment plan. The gradual rollout of OMH care and the need to use the new system for some payers while maintaining the old system for others has created a significant amount of work for everyone at the practice, but Tennessee Oncology has leaned heavily on consultants who have eased the transition.

“This model is new enough that it continues to evolve. New studies provide new evidence about best practices and require you to change a workflow shortly after you put it into place,” Horowitz said. “But OMHs aren’t such a new concept that practices need to implement them by pure trial-and-error or even on their own. There is outside help available, consultants who have put the model in place before and can help ease the transition at your practice. I can’t speak for others, obviously, but they sure have been helpful to us.”

References

1. National Cancer Institute; Centers for Disease Control and Prevention. Incidence rates table. State Cancer Profiles website. statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=47&cancer=001&race=00&sex=0&age=001&type=incd&sortVariableName=rate&sortOrder=default#results. Accessed April 21, 2017.
2. Tennessee Cancer Coalition. State of Tennessee cancer plan 2013- 2017. State of Tennessee website. www.tn.gov/assets/entities/health/ attachments/TN_Cancer_Coalition_State_Plan_2013-2017.pdf. Accessed April 21, 2017.
3. Centers for Disease Control and Prevention. Map of current cigarette use among adults. CDC website. www.cdc.gov/statesystem/cigaretteuseadult. html. Updated September 16, 2016. Accessed April 21, 2017.
4. Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. CDC website. www.cdc.gov/tobacco/ data_statistics/fact_sheets/adult_data/cig_smoking/. Updated December 1, 2016. Accessed April 21, 2017.
5. National Cancer Institute; Centers for Disease Control and Prevention. Death rate report for Tennessee by county: lung & bronchus, 2013. State Cancer Profiles website. statecancerprofiles.cancer.gov/cgi-bin/deathrates/deathrates.pl?47&047&00&0&001&1&1&1&1#results. Accessed April 21, 2017.
6. National Cancer Institute; Centers for Disease Control and Prevention. Death rate report for Tennessee by county: lung & bronchus, 2009-2013. State Cancer Profiles website. statecancerprofiles.cancer.gov/cgi-bin/ deathrates/deathrates.pl?47&047&00&0&001&0&1&1&1#results. Accessed April 21, 2017.