From informal discussions in 2004 to a ribbon cutting in 2008, Dana-Farber Cancer Institute (DFCI) and New Ham pshire Oncology-Hematology (NHOH) embarked on an odyssey to provide world-class cancer care in Londonderry, New Hampshire (Sidebar), according to Denis B. Hammond, MD, chief medical oncologist at NHOH, who detailed “why and how” a multisite, single-specialty adult hematology and oncology independent practice affiliated with an academic cancer center at the 2011 annual meeting of the American Society of Clinical Oncology.
“We were facing the first serious competition in our history, and we were also facing the same increased economic pressures all of us have been facing in the United States,” said Hammond. To help determine the best collaboration strategy, NHOH’s leaders posed themselves questions, as stated by Hammond:
- Would a closer relationship with another institution support our mission?
- Are the values of this other institution consistent with our own?
- Have we had successful interactions with this institution in the past?
- Is there an alignment of our strategic goals?
Their answers aligned well with DFCI. As a Cancer and Leukemia Group B affiliate with a strong commitment to research, NHOH believed that working with DFCI could improve the quality and scope of services it could provide patients, explained Hammond. Next, they needed to pursue building a successful relationship.
Informal discussion began in 2004, exploring the possibility of a closer relationship between NHOH and DFCI. In January 2005, according to Hammond, they signed a “memorandum of understanding,” which detailed the affiliation and the lack of a financial relationship. From this, the 2 groups developed programs, which included “opening selective DFCI trials at NHOH, a joint psychosocial research project, genetics clinics at some of our private practices, and a community education program called ‘Let’s Talk’ that featured physicians both from NHOH and DFCI,” he said.
Also that year, Elliott Hospital expanded its services from Manchester to Londonderry. This challenge offered an opportunity for shared clinical space and programs at this campus, said Hammond. In December 2006, NHOH signed a “letter of intent” to explore an agreement with DFCI, which would seize this opportunity and set up a shared financial relationship.
Provider Services Agreement Time Line
To go from intent to agreement, the 2 groups needed to determine what would work best. This feasibility analysis, said Hammond, asked:
- Where would the patients come from?
- How many patients would we likely see?
- What were the reimbursement issues?
- What were the regulatory issues?
- Could this relationship be structured so as not to alienate referring physicians?
- What type of financial relationship would be most profitable for both NHOH and DFCI?
- What model of care would work best: an NHOH office with DFCI affiliation (the status quo); a provider services agreement; a joint venture; NHOH as a wholly owned entity of Farber?
The entities decided upon a provider services agreement. “NHOH physicians would join the DFCI staff. [NHOH] would provide professional medical and support staff services. The administration of the unit would be carried out by DFCI, with the advisory function of an NHOH physician. There would be joint governance, and there would be a steering committee,” shared Hammond. “The basics of the provider services relationship would be that DFCI would rent the clinical space from Elliott Hospital and equip the unit according to DFCI standards. The staff would perform functions in accordance with DFCI policy and procedures. Neither party would take any action that would harm the other. And the clinic would utilize DFCI’s electronic medical record and computerized physician orderentry system.”
After DFCI signed the lease for clinic space at the Londonderry campus, DFCI and NHOH formalized their alignment by signing a long-term provider services agreement for that location.
Now a new entity, Dana-Farber/ New Hampshire Oncology-Hematology (DF/NHOH) has enhanced its services. To date, it has opened genetic, survivorship, and second-opinion clinics; developed joint tumor boards for multiple disease sites; opened DFCI trials in New Hampshire; and begun continuing medical education and community education programs, Hammond extolled. The group also has added staff: a full-time social worker (1 FTE), a nutrition counselor (0.4 FTE), and a chaplain (0.25 FTE). “Patient satisfaction has been high and clinic growth has continued through this present year [June 2011]. Additionally, there is now a fully staffed radiation oncology unit on site, and it is a group through which we have had a long relationship,” he said.
To conclude his presentation, Hammond shared how the affiliation has fared in the 2 years since the agreement was signed. Measuring new patients/consults per year, established patients per quarter, and infusions, DF/NHOH analyzed their projected versus actual numbers. For the first year, 2009, projected amounts mirrored the actual, he said; for the second year, 2010, the actuals were significantly lower than what was projected.
He offered this analysis of why the projections were off: “The projections were based primarily on the existing demographics of each of the entities involved in the project and did not take into account the subtraction that would happen when the 2 entities joined. In addition, the projections did not account for the increase in competition in the clinic’s catchment area. The projections also did not account for the fact that opening this clinic would alienate some of our referring physicians. And the projections did not account for the fact that some patients just wanted to go downtown for their care.”