 Cindy O. Scharfen, MD, radiation oncologist, and Shahab Dadjou, RRMG executive vice president, meet at one of RRMG’s nine locations |
On first suspicion of cancer, the typical patient finds himself thrust headlong into a crucible of dread. The longer the wait for a confirming diagnosis, the greater the anxiety. It was a desire to dramatically reduce such waiting that in part prompted formation of Redwood Regional Medical Group, a Santa Rosa, Calif-based enterprise that unites radiology, radiotherapy, and medical oncology services within a single practice.
“It is difficult to overstate the value of giving the patient a speedy answer,” says L. Wayne Keiser, MD, a senior medical oncologist with the group. He cites the example of a woman who arrives at Redwood Regional Medical Group at 8 in the morning for a mammography examination. “She departs 30 minutes later, with results already in hand. In a conventional model of practice, that same patient would probably be waiting the better part of a week to find out whether she was clear.”
But as useful as alleviating patient anxiety may be, this integrated model of practice delivers much more than the capability for quick reporting of findings. It routinely produces earlier and better diagnosis and treatment of cancer, with higher rates of survival the ultimate result.
BEST AND BRIGHTEST
 Amanda Edwards, oncology nursing coordinator, and L. Wayne Keiser, MD, senior medical oncologist, consult a patient chart. |
Redwood Regional Medical Group—said to be the largest practice of its kind in California and among the biggest in the nation—serves more than 400 patients a day at nine offices spread across Wine Country in Sonoma, Napa, Mendocino, and Lake counties. It came into existence in 1995, a product of the then 40-year-old Santa Rosa Radiology and its comparatively younger subsidiary Redwood Regional Oncology Center.
Redwood Regional Medical Group is built around a team of 40 board-certified physicians who include—along with the diagnostic radiologists, radiation oncologists, and medical oncologists—specialists and researchers in the fields of neuroradiology, interventional radiology, and hematology.
“Some of the best and the brightest physicians in the entire United States are part of our organization, and all are connected to academic centers,” says Shahab Dadjou, the group’s executive vice president.
Most patients come to Redwood Regional Medical Group by referral from primary care. The remainder are sent by urologists, internists, and other specialists. However, to avoid being perceived by local hospitals and physician groups as a potential business threat, Redwood Regional Medical Group downplays its size and stature.
“Those other providers and institutions are our partners in the care of cancer patients, so we stress the message that we’re community focused, that we’re working to help them better serve the community,” says Dadjou.
That is essentially how radiologist Harry E. Phillips, MD, sees it. “We’re able to help the community because, internally, as a group, we have united around a common set of goals. Those goals call for us to provide quality medicine, deliver good outcomes, and offer appropriate support to local institutions,” says Phillips, who joined the practice in 1982.
THREE-SIDED MODEL
The merger of which Phillips speaks was made possible by the organizational makeup of the group, which Phillips likens to a triangle. “We’ve placed the three main types of specialists at each apex and the patient in the middle,” he says. “This is a much more effective structure than the traditional linear model of care where you have the patient shuttling from specialist to specialist at many different sites. With our approach, services are combined under one roof. And all the specialists are part of the same team.”
The team aspect proves crucially important, Keiser adds.
“The pace at which care is delivered is appreciably slower if you have an oncologist working by himself or herself—or even in a small group—without direct connection to practices providing radiology and radiotherapy,” he says.
In contrasting older models to that of Redwood Regional Medical Group, Keiser suggests their deficiency lies in the way they leave the medical oncologist to decide on his own what will be done for the patient—whereas at Redwood Regional Medical Group the oncologist receives timely, cogent recommendations from the other involved services and can thus develop a cooperative plan of action.
“We make the decisions together, as a true team,” he says. “It works better that way because my teammates bring to the table expertise that enhances the quality of planning and the quality of care.”
Radiation oncologist Cindy O. Scharfen, MD, illustrates the point by referencing a recent Stage II head-and-neck cancer patient for whom CT and MRI tests of his lymph nodes gave no cause for heightened alarm—until, that is, a PET/CT examination indicated otherwise. “The PET/CT study was easily coordinated because of the way our group is set up, and it uncovered very high uptake in a normal-sized lymph node,” she says. “This finding changed the patient’s classification to Stage IV, and resulted in immediate alteration of his entire treatment plan.”
GAP-FREE COMMUNICATION
Essential to good teamwork is communication among the players. At Redwood Regional Medical Group, such interaction is frequent, immediate, and robust.
“Our experience has been that, the more communication there is, the clearer the understanding of the cancer problem we’re attempting to address,” says Phillips. “And the clearer the understanding, the more accurate the response. The more accurate the response, the better the chances of obtaining a good outcome. But when you’re multiple individual practices rather than a single integrated practice, there will be unhelpful gaps in communication.”
One of the virtues of having gap-free communication is that it aids oncologists in ordering the right diagnostic studies at the right time.
Says Keiser, “In a traditional model, it’s too easy to order a test that you think will provide the answers you need, but then doesn’t. Our model lets us go straight to the definitive test. In so doing, we’re providing a more cost-efficient route to the answer.”
And, commonly, this approach yields an answer that results in better treatment. Scharfen tells of a recent case in which one of her radiation oncologist colleagues was able to precisely target and deliver an appropriate dose of intensity-modulated radiation therapy to a head-and-neck cancer patient whose tumor was located very near the radiation-vulnerable brachial plexus. This feat of accuracy was made possible thanks to the manner in which the diagnostic radiologists contoured those images in response to the radiation oncologist’s concerns.
Milestones |
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Redwood Regional Medical Group traces its roots to Santa Rosa Radiology, a diagnostic imaging practice started in the 1950s by a quartet of radiologists in the city of Santa Rosa, just north of San Francisco. Listed are some of the milestones leading up to the formation of Redwood Regional Medical Group and charting its growth since then. 1966 Santa Rosa Radiology introduces nuclear medicine to Sonoma County. 1968 Adds radiation therapy, another first for Sonoma County. 1971 Further breaks ground by bringing in medical oncology specialists. 1976 County’s first CT scanner arrives at Santa Rosa Radiology. 1980 County’s first radiation oncologist joins the group. 1985 Group acquires the first MRI scanner in the northern San Francisco Bay Area. 1987 Interventional radiology procedures offered. 1989 Santa Rosa Radiology becomes first in the region to win American College of Radiology accreditation in mammography. 1991 Establishes Redwood Regional Oncology Center as a division. 1995 Redwood Regional Medical Group is formed by merger of Santa Rosa Radiology and Redwood Regional Oncology Center. Opens Fountaingrove Radiation Oncology Pavilion and introduces computerized treatment planning system for radiation oncology. 1996 Introduces conformal therapy, allowing for maximal treatment of prostate cancer. Redwood Regional Medical Group merges with Hematology Oncology Medical Group and Radiology Associates of Santa Rosa. 1999 Debuts the first open MRI in the North Bay Area. 2000 Introduces the first PET scanner in the North Bay Area. 2004 Redwood Regional Medical Group merges with Advanced Imaging Institute, opens The Integrated Breast Care Center, installs the North Bay Area’s first PET/CT scanner. |
“The radiation oncologist was able to treat without harming the brachial plexus,” Scharfen summarizes.
ONE FOR ALL
The various specialty sections within Redwood Regional Medical Group are financially intertwined: incentive—and risk—are shared equally, with compensation based on practice-wide performance rather than on productivity benchmarking of individual physicians (of which there is none).
“Our group is egalitarian; we’re all for one and one for all,” says Dadjou.
Some observers wonder how the relational structuring of the group can pass muster with federal Stark rules. Dadjou responds that the Stark safe-harbor provisions are met “because patients are never referred from one specialist or service to the next within Redwood Regional Medical Group.”
Because there are no intrapractice referrals, there are by extension no intra-practice referral politics—the absence of which delights Scharfen.
“It means we can be completely open and honest with one another in expressing views about how the patient should be cared for,” she says. “No one has any turf to defend, so the patient ends up receiving the very best care possible.”
A praiseworthy feature of the practice in Scharfen’s estimation is the monthly meetings between medical oncologists and radiation oncologists in which they plumb the most relevant new academic papers for insights that might help Redwood Regional Medical Group further improve outcomes.
“Gatherings of this sort seldom happen outside of academia,” she says.
Redwood Regional Medical Group’s academic sensibilities are most pronounced within the confines of its research section, the mission of which is to develop advanced imaging and drug protocols.
“Each variety of cancer is addressed with a specific set of imaging and treatment protocols, since individual cancer types have their own unique biologic properties,” Phillips reminds. “Our protocols are based in large part on published literature from major university centers, and are in a continual state of refinement as new discoveries become accepted science.”
Innovative protocols also find their way into the practice through Redwood Regional Medical Group’s designation as one of California’s two Clinical Community Oncology Program centers (there are fewer than 65 nationwide). “This makes available to us protocols not yet available to most other cancer centers,” says Dadjou.
SIZABLE TECHNOLOGY BUDGET
One of the challenges for Redwood Regional Medical Group is maintaining state-of-the-art imaging and treatment technology in the private practice setting.
“We’re in a fairly tight market as far as our margins are concerned,” he explains, mentioning that Medicare accounts for 45% to 48% of the group’s revenues, Medicaid (Medi-Cal) 6% to 7%, and the remainder private insurance.
The process of keeping up to date requires Redwood Regional Medical Group to annually assess its capital capacity by forecasting operating income 1 to 3 years out. Says Dadjou, “We factor in our balance sheet ratios, our risk tolerance, and our capability to finance capital acquisitions. From that, we can determine an amount to commit to technology acquisitions.”
The group considers its technology budgets fairly aggressive for a practice this size: total capital commitment for the years 2003-05 alone was $12 million. The preference is to purchase equipment outright, but, given the price tags affixed to the most major items, Redwood Regional Medical Group often elects to make capital lease arrangements. Bank credit lines are readily available, giving the organization the luxury of holding off on the plotting of its financing strategy until after identifying and settling upon the make and model of equipment it will buy.
Decisions as to what will be bought are made by the physicians who will operate or be directly responsible for the technology in question. However, those choices are tempered by input from the physicians who will be consumers of the equipment’s output or in some fashion utilizers of its capabilities.
When the practice buys or leases, it invariably aims to be first up in the local market with the newest and best that technology offers (a fact it touts in its outreach messages). The group’s current technology assets include three linear accelerators, two 80-leaf collimators, one 120-leaf collimator, and three treatment planning systems; and imaging assets include one 16-slice CT and one 8-slice CT scanner, four 1.5 MR scanners, one PET/CT scanner, one gamma camera, four 3D workstations, two R/F rooms and two general radiography rooms, three mammography units, one CAD system, two breast biopsy systems, and five ultrasound systems, all deployed among the nine offices, with the largest concentrations at the flagship facility in Santa Rosa. Santa Rosa also is home to a PET/CT system (Redwood Regional Medical Group in 2000 claims the honor of introducing the northern San Francisco Bay Area to PET).
Informatics, too, figure into the scheme of things: there is in place a full-blown RIS-PACS that includes the ability to store and retrieve each patient’s entire treatment plan. “Informatics for us clearly promotes synergy among the specialties,” says Phillips.
 The organizational chart for Redwood Regional Medical Group illustrates all practice components. |
RAISING COMMUNITY STANDARDS
Informatics helps extend those synergies beyond the practice’s four walls—over 117 outside physicians in more than 42 offices are tied into the group’s RIS-PACS. Some of the images and reports that those outside practitioners access relate to cases presented at a local breast cancer conference led by Redwood Regional Medical Group.
“We’re partnered in the breast-cancer conference with Sutter Hospital and Santa Rosa Memorial Hospital, plus local surgeons and pathologists,” says Scharfen. “This is a weekly tumor board where nontreated patients are discussed but also where the standards of care for the community are reviewed—the intent being to explore ways of improving those standards.
“We’ve made some rather encouraging progress in that regard. Consider what we’ve accomplished in sentinel lymph node biopsy—we now have very good standards for the proper marking of specimens in surgery, for making sure there are adequate margins in the tumorous section, for making sure the correct details are included in the pathology report. We’ve also improved ultrasound protocols, and talked to surgeons about placing clips for radiation planning.”
Above and beyond that, Redwood Regional Medical Group takes part in cooperative group clinical trials, such as the National Surgical Adjuvant Breast and Bowel Project, which involves some of the top academic medical centers in the country. Keiser, the medical oncologist, plays a role in facilitating the imaging components of these clinical trials. “There’s often a diagnostic radiology and a radiotherapy component to them,” he says. “Since these clinical trials are absolute state-of-the-art, the support we provide has to be university-level quality.”
In the years ahead, look for Redwood Regional Medical Group to bring aboard new specialties. Just this year, the practice enlisted a vascular surgery team and a team dedicated to breast surgery. Dadjou hopes next to attract groups offering neurosurgery and orthopedics.
“These groups might participate with us as close allies or loose affiliates, not necessarily as full-fledged, vested partners. We’re flexible,” he says.
Meanwhile, Redwood Regional Medical Group intends to standardize its satellites around a campus model of operation in which each site will have a full-time representative of—at minimum—the three primary services (radiology, radiation oncology, and medical oncology). Currently, the model is in use only at some of the sites.
“The campus model will help us further increase our value to the community,” promises Dadjou.
For his part, Phillips is guardedly optimistic about what lies ahead, just over the horizon. “Our future will to an extent be determined by forces outside our control, such as potentially adverse changes to Medicare and the rise of marketplace competitors,” he says.
Still, given the explosive advances in imaging and treatment technologies (coupled with the fact that there surely will be no shortage of cancer patients), things should turn out well for Redwood Regional Medical Group.
“My hope,” says Phillips, “is that we will continue on as an integrated, thriving organization that takes care of patients by means of the best doctors using the best equipment and the finest facilities. I think we’re very well positioned to accomplish exactly that.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.
