Working Together: How to Build a Radiosurgical Center and Partnership

1
Working Together How to Build a Radiosurgical
Center and Partnership

• Sandra Vermeulen, M.D.
• Seattle Cyberknife Center
• at
• Swedish Cancer Institute
• Seattle, WA

2
Swedish Cancer Institute Background

• Radiation oncology providers for 7 facilities in
  Puget Sound area
• Swedish Hospital at First Hill
• Swedish Providence Campus
• Seattle Prostate Institute
• Northwest Hospital
• Valley Medical Center
• Highline Hospital
• Stevens Hospital
• 15 radiation oncologists treat 220 external beams
  patients per day, and perform 600 brachytherapy
  and 300 Gamma Knife procedures per year

3
Seattle Cyberknife Driving Force

• Private Medical Investment Group
• Assessed a need in Seattle area
• Approached regional hospitals and medical groups
• Intent to partner with prominent neurosurgical
  and radiation oncology groups
• Swedish Hospital logical partner choice
• Largest oncology provider in the region
• Large neurosurgical and radiation oncology
  services

4
Swedish Radiation Oncology Physician Group
Decision Process for Participation

• Stereotactic Radiosurgery is there a need?
• Do clinical studies support hypofractionated,
  stereotactic treatment?
• Are there sufficient patients to justify the
  device?
• IGRT Platforms is the Cyberknife the best?
• How about Trilogy, Synergy, Tomotherapy?
• Financial Analysis does it make sense?
• What physician resources are required, and what
  reimbursement will be realized?

5
Stereotactic RadiosurgeryIs there a need?

• GammaKnife experience proved efficacy of cranial
  SRS frameless systems allow fractionation
• For extra-cranial SRS, literature review showed
  clinical efficacy in
• Spine
• Head and neck
• Lung
• Liver pancreas
• Previously radiated sites
• Population of the region, and size of Swedish
  network sufficiently large to justify SRS unit

6
The World of Image-guided RTIs the Cyberknife
the best?

• Few people really understand the differences in
  platforms
• Slow dose-rate limits throughput
• Swedish Hospital had Elekta Synergy S Unit, and
  will be clinical/research development site
• Advantages of Cyberknife over other platforms
• Cyberknife only image-guided platform with
  real-time target correction capability
• Only device with model to track respiratory
  motion
• Greater degree of targeting freedom theoretically
  yields superior dose delivery

7
Cyberknife
8
Financial Analysis Does it make sense for
radiation oncology group?

• What did radiation oncologist using CK say?
• Amazing technology, excellent clinical outcomes
• Enormous amount of work
• Reimbursement was awful
• Just say no, unless additional compensation
  given
• Financial per formas hospital versus professional

9
Projected Hospital Revenue from CK Center

• A successful CK center breaks even in year two,
  and can bring in 1-2 million/yr in 4 - 5 years

10
Professional Radiation Oncology Revenue from
Cyberknife SRS

• Ratio of revenue for equal work ext beam CK
  3 1
• (!)

11
Radiation Oncologists Reimbursement

• Why so poor?
• SRS management codes (77427, 77431) not yet
  reimbursed for extra-cranial treatments
• Radiation oncology billing historically weighted
  heavily towards weekly management fees
• Treatment planning codes undervalued relative to
  work effort required
• Treatment planning effort can be shifted to
  surgeon (CPT code 61793), increasing patient load
• Shift in mindset must be comfortable having
  other disciplines participate in contouring and
  planning

12
Planning the Treatment Center

• Stand-alone center?Association with existing
  radiation oncology facility allows
• Efficiencies in office space
• Efficiencies in staffing
• Physical space hire architects experienced in
  medical construction
• Corridors need to accommodate gurneys?
• Bathrooms, dirty clean utilities, etc

13
Assigning StaffCyberknife is Complex, New
Technology

• Uncertainty at every step
• Indication for treatment are evolving
• Treatment protocols are not well defined
• Every patient requires justification with
  insurance company
• Multidisciplinary treatment requires education
  and participation of numerous MDs and staff
• Numerous steps require coordination
• Fiducial placements require IR currently
  their work is not reimbursed
• Treatment planning processes (CT requirements, MR
  fusion) are unique, require forethought

14
Staffing

• Hire motivated, smart staff, preferably with
  experience in radiation oncology
• Assign a manager to oversee the project
• Physicists are expensive and hard to find
• An organized, efficient RN or coordinator, is
  needed that can multi-task well
• Assign a technologically savvy, high-performing
  therapist

15
Plan in Advance!

• Have manager and staff members in each domain
  trained through Accuray
• Have staff members (MD, physicist, RN, therapist)
  proactively plan office requirements
• Office supplies
• Examining room equipment and supplies
• Patient charts
• Treatment equipment
• Physics QA requirements

16
Educate Ancillary Departments

• Develop written CT and MR imaging protocols
• For CT slice thickness, pitch, images, center,
  patient position, contrast agents
• For MRI location and size of matrix, scanning
  interval, sequence, contrast agents
• Interventional radiology crucial for fiducial
  placement
• Meet with MDs, radiology office manager to
  explain program
• Reimbursement is a problem but other diagnostic
  studies can off set their time
• Explain detailed requirements of fiducial
  placement

17
Insurance

• Regional Medicare intermediary initially not
  paying professional fees for extra-cranial SRS
• Will this be treatment be reimbursed?
• Meet with medical director, present literature
• Other carriers may be reluctant to pay
• Meet with medical directors in advance
• Be prepared to justify treatment with literature
• Write letters of medical necessity

18
Educate Your Referral Base

• Market to physicians
• Relationships with referring doctors
• Presentations at tumor boards, grand rounds, etc
• At local hospitals and regional facilities
• Open house
• Direct informational mailings
• Market to community
• Local media papers, television
• Website

19
Clinical Considerations

• Extra-cranial SRS is new and few have
  experiencing training
• Well-established treatment guidelines dont exist
• Follow-up and complication data on
  hypofractionated body SRS is limited

20
To Determine Clinical Guidelines

• Attend the Cyberknife Society meetings
• Read the literature CK Society has a good
  reference list
• Review radiobiology
• Talk with other CK Society members
• Amount of information is overwhelming, so assign
  disease sites to different doctors
• Agree on guidelines for each disease site/stage
• If there is no literature on a treatment
  approach, submit formal protocol to your hospital
  IRB
• Consider gathering data on dosing, toxicity, and
  clinical outcomes to guide future treatments

21
Summary

• Realize enormous work effort required to start
  center and treat CK patients
• MDs should evaluate in advance the financial
  implications of participating
• Hire best available staff, preferably with
  radiation oncology experience
• Get trained and organized in advance
• Pro-active involvement education of
• Insurance companies
• Ancillary services (intervention radiology)
• Uncharted clinical waters physicians do your
  homework, and cautiously write protocols/guideline
  s.

22
Conclusion

• Cyberknife is a marvelous technology, that
  offers non-invasive treatment instead of surgery,
  or pain relief instead of morphine, or hope when
  before there was none.