Andrew L. Pecora, MD
We have been asked on numerous occasions why would almost 100 oncologists—with thriving successful private practices in New Jersey and many who have been in business for over 30 years—“give up their independence and identity in their community” and become part of Regional Cancer Care Associates (RCCA), a new entity with a single tax identification number?
The answer may not be immediately intuitive and in fact seems contradictory, but these oncologists joined together to maintain their independence and ability to deliver quality value based cancer care from their offices. Consolidation is happening everywhere in the new health care market where several macroeconomic forces are driving seismic change.
First, the overwhelming need to reduce unit cost of care and utilization of “unnecessary” care has created a tide that’s pulling all providers towards new geographically scaled delivery systems that will enable reductions in cost of service delivery and greater oversight of care utilization. Second, stability of the amount and reliability of reimbursement for services provided is deteriorating.
This instability pressures small (meaning limited in number and geographic coverage) independent providers to consider offsetting this risk by shuttling patients to larger and bettercapitalized providers.
Third, the increasing inability of small providers to influence decision making by larger care systems and payers leads small independent providers to give up their independence.
In cancer the problem is even more acute. With fewer people dying of cardiovascular and infectious diseases, and more cancer patients living longer with active cancer who require ongoing and ever increasingly expensive care, the rate of growth in the total cost of cancer care delivery is now thought to be unsustainable. While major breakthroughs of inexpensive interventions to prevent and treat early cancer remain possible, the current trajectory of cancer care cost growth has engendered a national discussion regarding controlling cost through limiting (rationing) access to care in general or attempting to eliminate unnecessary cancer care at scale.
RCCA was created to enable the latter approach, the so called Goldilocks formula—not too much care, not too little care, but just the right amount of care at scale. Those involved in the formation of RCCA understood that to have a measurable impact, RCCA needed to involve a large number of geographically dispersed oncologists (and their staff) to implement value based cancer care delivery at scale. Having a single tax identification number allows joining practices to maintain local managerial control and internal business agreements between partners and employed physicians. Centralized services are available to local divisions on a cost basis without any profit motive. To join RCCA physicians must agree to be focused on value based care delivery; however, RCCA delivers on its promise to maintain “local” practice independence.
RCCA was incorporated on January 1, 2012, from 10 existing and separate oncology/hematology practices distributed throughout the state of New Jersey representing care providers from every county. In 2013, RCCA added 3 additional practices in New Jersey and opened a Blood and Marrow Stem Cell Transplant program at the Georgetown MedStar University Hospital in Washington, DC, and now is expanding to include physician practices from other states.
RCCA currently includes over 100 boardcertified oncologist and advanced practice nurses supported by over 600 additional staff providing services from 26 locations throughout New Jersey and Washington, DC. With over 20,000 new patients (oncology and serious blood disorders) treated by RCCA physicians annually, and following one set of standards that are evidenced based and also accounts for cost of care, RCCA’s integrated care delivery provides a large number of patients access to care that is not redundant, has limited variance from the standard, accounts for cost using the most cost efficient care and access to an extensive array of clinical trials to avoid futile care.
As a first effort to demonstrate value-based care delivery at scale, RCCA launched evidencebased imaging guidelines that reduced excess imaging and had greater than 95% compliance. To encourage and repeatedly drive value based care delivery, RCCA physicians will track and report on clinical outcomes and cost of care by disease, segregated by histopathology/response to therapy, and implement relevant prognostic testing using software currently available to all RCCA care providers regardless of their EHR type.
To control cost and quality, transitioning from fee for service to at risk (bundled) contracts is being considered by payers across the country.