Aggregation Lets Independent Practices Compete and Grow

Community oncology faces competitive headwinds but a recent case study involving Alliance Cancer Specialists, a group practice in The US Oncology Network in the Philadelphia area, showed the benefits of collaboration for oncologists.

The case study¹ outlines how independent practices were competing individually against large academic institutions in the area. As Alliance President Allen E. Lord Terzian, MD, said, his standalone practice was under “financial strain.” Starting in 2008, he was able to merge 4 independent practices into one larger practice as Alliance Cancer Specialists. Alliance later brought on The US Oncology Network as its practice management company and by 2022, the number of medical oncology providers operating under the arrangement climbed to 56, across 19 sites of care. Two radiation facilities were added, and primary care collaborations were achieved. According to the case study, “The Network practices became the preferred oncology provider by one of the largest payers in the region.”

Evidence-Based Oncology™ (EBO) spoke recently with Terzian about the experience. This interview is edited for length and clarity.

EBO: Can you discuss the recent case study that shared the benefits of aggregation for independent oncology practices in your area?

Terzian: We were originally a small practice of 5 or 6 physicians until 11 years ago. I realized at that time that we couldn’t continue to survive in the present market. The environment and competition from the hospitals have actually become much worse since then. We met with multiple other practices in the Philadelphia area and eventually put together a 23-person oncology group from 4 different practices.

Over the years, the majority of oncologists in private practices in Philadelphia became employed by hospitals. There were only a handful of independent practices left, and 2 of them joined Alliance after we became part of The US Oncology Network.

So that’s the background—we’ve been a big practice for a long time, but now we are much bigger after joining The US Oncology Network.

EBO: The case study described your ability to develop efficiencies. Can you discuss some areas where you’ve seen savings or achieved greater cost-effectiveness?

Terzian: We get better supply and drug pricing as a bigger group. I think it has allowed us to afford things we couldn’t have afforded as a small group, including ancillary services, a pharmacist, HR and a CEO. Everything’s cheaper when you buy in bulk. So, there are lots of economies of scale.

I think we’ve learned a lot from each other being in a big group, because we communicate. When you’re an isolated 5-person group, as opposed to talking to another 25 to 30 colleagues on a regular basis, you’ll learn things both from a business standpoint and clinically about patient care, and that’s been a big advantage.

EBO: Over the past decade, we’ve heard so much about the importance of data in cancer care, whether we’re talking about precision medicine or the role of real-world evidence in drug development. Can you discuss how aggregation has helped you in some of these areas?

Terzian: One of the problems with data is that it’s all ICD-10 [International Classification of Diseases, 10th edition]-based claims data for insurance companies. The ICD-10 codes were very poorly developed by Medicare and have virtually no clinical relevance. So, for example, for a woman with breast cancer, the insurance companies know that the breast cancer was in the upper outer quadrant of a right breast. But that’s really all they know—they don’t know the stage, what the hormonal markers are, whether she’s HER2 positive; biologically they have no idea what’s going on. It is a very diverse group of patients just for breast cancer alone. Lung cancer is the same way as well as many other cancers. It’s not one disease anymore—it’s many, many diseases.

So, to get meaningful data, you need [electronic medical record] EMR data and merge it with claims data. If you want to look at meaningful cost data, it’s very difficult to do right now.

We have lots of EMR data, and we can run reports on almost anything we want. We have a lot of data from The US Oncology Network also, because of their [national data sets]. So, it’s helped us a lot in patient care.

EBO: Are there things you can do now with data post aggregation that you wouldn’t have been able to do as an independent practice, or things you can do now more effectively?

Terzian: Obviously, the more data you have, the better it is. So, when you’re a small practice, your data may be skewed by a few outlying patients; the larger you are, the more accurate it is. [Joining] The US Oncology Network has helped us to have better data analytics. They have analytic data on 2000 providers nationwide, so we have a baseline for comparison.

EBO: When you were looking ahead years ago and you didn’t think your practice could survive, why did you feel aggregation with other oncologists locally was the best option? Why did you see that as a better option than being acquired by a hospital?

Terzian: First, independent doctors are happier in general. You’re more in control of what you’re doing on a daily basis. Happier doctors make better doctors. Employed doctors, I think are generally less happy and are under more stringent requirements of the hospital system. For example, I’m independent, so I can pick whomever I think is the best surgeon in the city for a patient who needs a liver. So, I have my choice of 20 different surgeons. Whereas, if you’re an employed physician, you must refer generally to whomever is at that institution, or in that hospital system.
Care from independent practices is much less expensive than [hospital] owned practices, often by a factor of 2:1. I think our care is more personalized or much more concierge–like than it is in a large university—or even a hospital-based practice. There’s much less bureaucracy; we get things done faster. Our employees are our employees; they’re not hospital employees. We can hire the right people to do the right jobs without the outside influence of a hospital system. We can instill a culture in our employees to have compassion for patients, and we offer patient experience that I don’t think you can get from a hospital system.

EBO: There’s been a lot of focus in the last several years about getting more patients into clinical trials and getting more minority patients into clinical trials. Can you discuss the landscape of getting patients enrolled in trials today, say, compared with 5 or 10 years ago?

Terzian: Things have changed a lot. There have been a lot of advances in oncology in the last 10 years; the number of new drugs coming out just took off logarithmically about 10 years ago, I would say. And the clinical trials back then were mostly large group trials, like ECOG [European Cooperative Oncology Group] trials and NSABP [National Surgical Adjuvant Breast and Bowel Project]. You know, I think those trials are still important, but more of the trials now are pharmaceutical trials with new drugs. Most of those trials are driven by molecular defects, with more biologic agents. The drug development has just skyrocketed. Now, a lot of clinical research is done in the community in the United States. So, with The Network, we have access to an enormous number of trials; the number of trials that we will have available should continue to expand.

I think it’s easier now to enroll patients. Decades ago, there were just a handful of group cooperative trials that you’d be interested in. Now, there are many drug trials that are very interesting.

EBO: What is it like to coordinate with a patient’s primary care practice today, compared to previously? Today patients can be living with cancer for a decade—patients with multiple myeloma offer a good example. Being a community practice, what does care coordination with primary care look like today?

Terzian: We work very closely with the primary care physicians. This is another difference between being in community oncology and being employed. We encourage primary care practices to send us patients early, even with just an abnormal CAT scan. That way we can do the work up quickly and get things going in the right direction. The patients are living much longer—for patients that are actively on treatment, we almost become the internist for the cancer patients. Some [patients] don’t see their family doctor that often while they’re getting cancer treatment because they’re seeing us so much. During that time, we take care of their problems, obviously [we’re] coordinating with the [primary care] doctors about things that need their attention. For patients who are living much longer that are on maintenance therapies who don’t have a lot of side effects, we see them less frequently, and the family doctor sees them more frequently. But communication is the key to all of this. 

Reference
The freedom of autonomy with the strength of numbers. Case study: the Philadelphia metro area. The US Oncology Network. Accessed September 1, 2022. https://bit.ly/3UuVxWu

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