Spring 2016

Stanley M. Marks, MD, is chairman of the UPMC CancerCenter, in Pittsburgh.

Commentary Overview

* The UPMC CancerCenter network is organized along a "regional hub and satellite" structure, with outpatient care offered at more than 40 regional sites.

* UPMC CancerCenter, in partnership with the University of Pittsburgh Cancer Institute, an NCI-Designated Comprehensive Cancer Center, combines a strong research institute and a broad clinical network with state-of-the-art technology, thus enabling quick translation of the latest research advances to clinical applications.

* Ensuring that the same level of consistent, high quality care delivered at the hub facility is experienced by patients at satellite locations requires uniform policies and procedures.
About AACI Commentary

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A Network Model for Innovative Cancer Care Delivery

BY STANLEY M. MARKS, MD

UPMC CancerCenter is one of the largest oncology networks in the United States, treating more than 74,000 patients each year at facilities in western Pennsylvania, West Virginia, Ohio and abroad, including 19 medical oncology centers, 13 radiation oncology centers, ten dual centers and four international centers.

The University of Pittsburgh Cancer Institute (UPCI) was founded in 1985 by Ronald B. Herberman, MD, and is currently led by Nancy E. Davidson, MD. UPCI is an NCI-Designated Comprehensive Cancer Center with more than 300 faculty researchers and over 4oo active clinical research trials. Its federal funding includes three Specialized Program of Research Excellence (SPORE) grants --head and neck, lung, and skin cancers--and a SPORE grant in ovarian cancer shared with Roswell Park Cancer Institute.

The combination of a strong research institute—UPCI—and a broad clinical network with state-of-the-art technology enables the rapid translation of the latest research advances to clinical applications for all patients.

Regional Hub and Satellite
The UPMC CancerCenter network is organized along a "regional hub and satellite" structure. Outpatient care is offered at more than 40 regional sites, while inpatient and specialized treatment is provided at a central hub--Hillman Cancer Center--housing 15 specialty care centers and multiple programs.

A regional patient care model carries a number of advantages:
• Joint ventures/partnerships foster collaborative relationships with non-UPMC hospitals and result in wider access to cancer care
• Patients benefit from improved access—traveling to the city is often unnecessary
• Presence in the community results in local acceptance
• Centralization of specialized/complex and inpatient activity lowers overall investment
• Knowledge and technology transfer to local healthcare professionals is facilitated

As part of a network-wide integrated care model, a centralized management structure for all oncology services throughout UPMC allows for seamless coordination of patient care across facilities and physician groups. Both academic and clinical faculty at the hub and clinical faculty at satellite (spoke) sites benefit from all disciplines which collaborate closely on patient care issues.

Other features include video-teleconferencing facilities allowing all network physicians to access oncology grand rounds, tumor boards and clinical research meetings conducted at the central facility. Surgical and behavioral medicine consultation, nutritional services, financial counseling, and other services are available at numerous locations throughout the network. Hand-held devices provide physicians at all locations with access to open clinical research trials so that patients can be screened for study enrollment during their visit.

In addition, representation from all sites on central committees allows for the standardization of policies and procedures across the system and a unified delivery of care. Referrals can be handled in a variety of ways, coming into Hillman Cancer Center or directly to a community site, with additional referrals for specialty care are provided to other sites (including hospitals) as needed.

The UPMC CancerCenter network is structured along four basic types of relationships:

1) Joint venture partnerships foster an alignment of interests that leads to improved results, co-branding and contracting leverage. Partners share equity in the venture with day-to-day management provided by UPMC. The majority of non-UPMC relationships in terms of the network are joint ventures.

2) Management agreements maintain the existing legal structure or ownership while allowing involvement of a clinical partner with long-term expertise in managing cancer centers.

3) Advisory/consulting arrangements begin as a short-term agreement with an expectation for a long-term agreement. UPMC provides recommendations to improve an existing cancer program, including identifying gaps in clinical care.

4) Affiliation agreements provide support in specific areas only, with no UPMC branding.

Financial Considerations
The payer mix for UPMC CancerCenter, and for healthcare across western Pennsylvania, continues to shift away from commercial to more government payers (Medicare and Medicaid) that typically pay less than cost. UPMC is an IDFS (Independent Delivery and Finance System), but more than half of its volume continues to be fee-for-service, which makes shifting from volume to value difficult but necessary—how, and when, we make the shift is a daily discussion.

UPMC CancerCenter does not include hospitals that are exempt from the normal Medicare payment process for its cancer business, and it currently depends heavily on 340B drug pricing, with the federal Health Resources and Services Administration continuing to propose new, more restrictive guidelines that will make participating more difficult. In addition, radiation oncology continues to move more toward hypofractionation (providing radiation therapy over a shorter period of time--fewer days or weeks--than standard therapy) yet payment continues to be made on a per-treatment basis.

A Single Standard of Care
Ensuring that the same level of quality experienced by patients at the hub facility is delivered at satellite locations is vital for the success of a large network. Clinical pathways – provided since 2005 through VIA Oncology Pathways, a web-based technology developed by UPMC – provides physicians with evidence-based treatment protocols for cancer. The pathways are implemented across disciplines and compliance is regularly monitored.

VIA Oncology Pathways are used at both the hub as well as satellites. They differ from National Comprehensive Cancer Network (NCCN) guidelines in that there are typically one or two options as opposed to many options, with pathways now covering about 98 percent of patients. Clinical trials are embedded in these pathways, with many trials open at community sites as well as the hub.

Committees are set-up within VIA Pathways for each disease site, and participation is open to full-time as well as clinical faculty to ensure that there is full agreement before a pathway is finalized.

Bringing a consistent, high standard of care to UPMC's wide network also involves uniform policies and procedures. These include weekly monitoring of patient satisfaction, access to patient navigators, case managers, and social workers, medication variance and adverse event reporting, an active quality improvement team to address process issues (e.g., patient wait times at the hub; communication between staff and patients at the satellites), education for all levels of clinical and professional staff, and regular billing, compliance, and medical audits.

Beyond facilitating the delivery of advanced technologies at many community sites, the partnership between UPMC CancerCenter and UPCI enhances the performance of basic, translational, and clinical research, the education of the next generation of cancer researchers and physicians, and ultimately, our contributions to the global effort to reduce the burden of cancer.

Representing 95 of North America's premier academic and free-standing cancer centers, the Association of American Cancer Institutes is dedicated to reducing the burden of cancer by enhancing the impact of the nation's leading cancer centers.