The Metamorphosis of a Community Oncology Practice

Most narratives referring to a metamorphosis of a community practice end with the practice evolving into a health system or valiantly maintaining their independence through thoughtful design. This is not one of those stories. This is the chronicle of how one community oncology practice — over the course of roughly five decades — engaged with patients but disengaged with industry trends, picked the wrong side in a war of attrition, marched naively into the mouth of a giant and, subsequently, lost a few limbs during its exit. But this is not a story of its undoing. It’s a story of its rebuilding … through new partnerships, new technologies and a renewed commitment to its founding principles. 

Dr. Tracey Weisberg, president and lead physician at New England Cancer Specialists, helps to tell it. As she says, "We have a voice. As community oncologists, we need to use our voice to be present for both our patients and fellow physicians. It’s in the preservation of these relationships that we will find what we need to survive."

The 1960s

“They knew everyone’s name. It was all about high-touch care. There were no oncology boards, no electronic health records (EHR). Handwritten records were kept in the barn.” –Dr. Weisberg

Picture a large, colonial-style home set on the eastern promenade of Portland, Maine. A stroll around the grounds reveals a backhouse of almost equal proportions to the main house. Inside, cancer patients wait to see Dr. Ronald Carroll, Maine’s first medical oncologist. This is where New England Cancer Specialists got its start, and where our story begins.

With little more than a stethoscope, pen and paper, one doctor does it all. Dr. Carroll sees patients in his residential medical center, he’s on call 24/7, he makes home visits and attends deaths.

Late 1970s and 80s

 “Now they had an actual treatment room. Patients were no longer being seen in a bedroom that had been made to look like a therapy room.” –Dr. Weisberg

The practice has a revelation: One doctor cannot do it all. Two partners are brought into the fold to help. Also, the decision to move out of the residential home and into a professional office is made.

Maine Center for Cancer Medicine (later to be renamed New England Cancer Specialists) is made official, complete with actual treatment rooms and a receptionist. 

Early to mid-1990s

 “We were so engaged with the hospital. We performed rounds at the hospital twice a day and went to every staff meeting. Hospital dinners, cocktail hours and holiday parties … everyone went.” –Dr. Weisberg

As cancer diagnoses and treatments grow, so too does the practice. It opens a satellite office in Brunswick, Maine and launches rural clinics. More doctors are added to the team, including the practice’s first female oncologist, Dr. Weisberg. The practice also begins to conduct clinical research. No one is discussing money, just growth.
In addition to performing rounds at the hospital twice a day and attending all the hospital’s meetings and events, the practice has access to the hospital’s doctor’s lounge (land of the free coffee and doughnuts). It is here the oncologists find where their next consult will come from.  

Beyond the doctor’s lounge, rising hospital admissions caused by 5-fluorouracil (5-FU) infusions and negative reactions to chemotherapies are keeping the practice staff working around the clock. 

Late 1990s

“We wanted to be the hospital’s right-hand man. We shared our research results and helped them open multi-disciplinary clinics, including the creation of a Breast Cancer Clinic. We were the only ones, however, paying rent.” –Dr. Weisberg

In addition to hiring its first physician assistant, the practice adopts its first EHR system. While some members of the staff are certain of the value medical data will have in the future, the physicians aren’t sure how to collect it. This later proves detrimental. 

The practice feels they are a valued collaborator with the hospital. When the opportunity to move into a hospital-owned building presents itself, it jumps at it.
Still, no one is discussing the financial viability of the practice. Does anyone know?

2006

“Oncology was changing all around us. Sequestration and the Sustainable Growth Rate (SGR) were a yearly concern. Hospitals were buying practices. We heard about 340B and ACOs … but we thought other people were going to have to make the hard changes. Then they’d see how bad it was and we wouldn’t ever have to do anything.” –Dr. Weisberg

The practice hires a CEO with an MBA to help run the business side of things. It incorporates genetics into the practice and more physicians are added to the team. The practice forms a joint venture with the hospital to open a fourth site in Sanford, Maine. And though it vexes the partners, they must migrate to a new EHR system.

Disenchanting discourse ensues between the hospital and practice over how to handle drug replacements and the treatment of free-care patients. The doughnuts and coffee in the hospital’s doctor’s lounge are no longer free, nor is parking for the practice. Soon, the hospital closes the lounge completely.  

2009 to 2011

“We almost die. The partners are not keeping any eye on the business.” –Dr. Weisberg

The partners cannot figure out how to get paid for genetic testing. They question the expense of clinical research. Spend on drugs is escalating. To add insult to injury, the CEO with the MBA demonstrates a desire for the practice to be absorbed by the hospital.

The hospital census is getting higher. And while its residents do less, the practice does more. Its oncologists are often up all night on call. The practice has no access to the hospital’s hospitalists. 

Meanwhile, the insurers inform the practice that they may be the least expensive cancer care in the entire state. But because there are no useful data in the EHR, the partners cannot substantiate such a claim.

In an ironic twist, the practice must once again migrate to another EHR.

The CEO and the practice go their separate ways. 

2012

"At this point the practice is in what I refer to as the winter of its business cycle. There’s only two things one can do in winter: Die or innovate." –Dr. Weisberg

The practice creates a formal leadership team and hires a new CEO, Steve D’Amato. He’s a risk taker and understands no practice will survive without moving forward. 

Step one in the new agenda: Orchestrate a plan to ensure individualized care while expanding the practice. This will demand operational insight and efficiency. The decision is made to partner with a third-party oncology supply company.

Step two: Establish an identity apart from the hospital. This begins with a name change. The practice is reborn as it remains today: New England Cancer Specialists.
With a renewed commitment to its patients and employees, the practice works to create a brand. 

2013

“It was like a Cold War. We were asked to go into consultations with the hospital to discuss alignment. They did not like our new business plan.” –Dr. Weisberg

The practice is now active in ASCO and ACCC. It starts to advertise and tell its story. This puts even more tension between the hospital and practice.

New England Cancer Specialists is selected to be a COME HOME practice. While this results in its having to refine its EHR, the partners now know how to collect data — and its value. Through COME HOME, it develops relationships with oncology organizations that share EHR, best practices, approaches to team-based care, paths to enhanced access and financial support.

The insurers are asking the practice to partner with them on payment reform projects. Physicians align and engage in patient pathway committees. Although fiercely independent, the practice is no longer alone. 

Today

“We received our oncology medical home accreditation in 2015. And boy did it deliver. We have fewer ER visits, fewer ambulatory-care sensitive hospitalizations. Our readmission rate is lower.” –Dr. Weisberg

Through captured data, New England Cancer Specialists realizes it is in fact the least expensive cancer care in Maine. In colon cancer, it is almost $40,000 less per patient. In breast cancer, about $20,000 less. In prostate cancer, $10,000 less. 

“It’s not just the drugs,” says Dr. Weisberg. “It’s that our doctor’s are thinking harder. They’re not admitting patients to the hospital. They’re using more thoughtful radiation techniques. They’re going to lower site cost of care for imaging and other services.”  

While it wasn’t the easiest path (or the shortest), the practice has managed to evolve into what it wanted to be 50 years ago: A place of personalized, high-quality care embedded in advanced technologies and cancer treatments. Equally important, it now has a voice and a story to tell — one that might encourage other practices to engage, transform and accept risk. Because, as illustrated by New England Cancer Specialists, staying the same is not an option for survival. “If you don’t execute you die,” says Dr. Weisberg. “If you make a mistake, you’ll figure it out. You’ll find another solution. But to just sit there, that will lead us to certain death.”