“Our vision is to drive the next generation of cancer care in this country, to deliver the same type of advanced cancer care that is expected at academic institutions to all patients, no matter where they live.”
By Matthew Ong
Community oncology needs to adapt to the era of precision oncology and Big Data, said Lee Schwartzberg, executive director of Memphis-based West Cancer Center, who was recently named chief medical officer of OneOncology, a partnership between three oncology practices located in Tennessee and New York.
“This creates a complexity issue in providing optimal care, which can be difficult to manage at a community oncology level,” Schwartzberg said. “A good part of what I plan to do is to help develop the tools and resources to allow practitioners—whether they sub-specialize like at West or if they are generalists at a small community practice to provide the highest-level care beyond what is available now.”
OneOncology, a partnership between three community practices—Tennessee Oncology, New York Cancer and Blood, and West Cancer Center—connects 255 providers that treat over 150,000 patients per year. The individual group practices also share a technology platform: Flatiron Health’s OncoCloud.
“We just got started with the three founding members; we plan to add about five additional practices in 2019. Our goal by 2021 is to have approximately a thousand providers in the network,” Schwartzberg said. “But I want to emphasize that we’re looking at quality over quantity, we want the best practices in any given region to be partners in OneOncology. It’s not at all a land grab. We want the best, because quality is so important to our mission.”
Schwartzberg spoke with Matthew Ong, a reporter with The Cancer Letter.
Matthew Ong: What is OneOncology’s genesis story? How many practices did you have in the beginning?
Lee Schwartzberg: About two years ago, leaders at three practices—Tennessee Oncology, New York Cancer and Blood, and my own, West Cancer Center—started having informal discussions about how we could best address the marked changes which are happening in cancer care.
All three of the practices were already successful on their own, but felt the need to join together to affect real change in the community oncology setting. Our vision is to drive the next generation of cancer care in this country, to deliver the same type of advanced cancer care that is expected at academic institutions to all patients, no matter where they live. As people are now living longer with cancer, the need for convenient, state-of-the art care is becoming increasingly important.
This need was the genesis for OneOncology—we partner the best community oncology practices in the country, leverage their expertise and deliver better quality, easier access, and lower costs to drastically improve the patient experience.
MO: Was the Flatiron affiliation coming around at the same time as you were creating OneOncology? What was the timeline in terms of Flatiron’s role?
LS: As we were creating the vision for OneOncology, it was very important for us to have a common technology platform across all the practices, so we could create analytics that would be deployed and shared with all of our practices. So, their role as a partner providing technology was integral from the start.
MO: How many providers and individual practitioners do you currently have in the OneOncology network, and how many patients and cancer cases does the network treat every year?
LS: We have about 255 providers in the three founding practices, and those practices treat over 150,000 patients per year.
And I’ll note that the practices are not exclusively medical oncology and hematology, but are to various extents multidisciplinary, including radiation oncology, surgical oncology, gynecologic oncology, diagnostic and conventional radiology, and other cancer professionals.
MO: Would you call OneOncology a consortium? How is OneOncology different from the standard model for consortia in oncology?
LS: I think the relationship with OneOncology is a closer and more collaborative partnership among the practices. Our connected ecosystem allows us to learn from each other; we’re going to be harmonizing our business processes, we’ll be creating pathways for treatment that will be deployed across all the practices.
Our goal in this network is to maximize efficiency in every aspect of cancer
care. And that includes such factors as the quality of care and access to care— we’re very interested in this as community oncologists. We want to ensure equity for all patients who are treated in the community.
As you know, over half the patients in the country are treated in community oncology settings, and that gives us an opportunity to improve the access, quality and experience while reducing costs.
We’re going to be building patient care teams that will allow the patient experience to improve, so I think it’s a global kind of approach as opposed to forming a consortium over one particular aspect of cancer care. It’s really a 360-degree view of the way that cancer care is delivered.
MO: What will your role be as chief medical officer? How is clinical care and research evolving in the community and what’s your plan for ensuring that OneOncology is keeping pace with that progress?
LS: I’m very excited about being appointed the chief medical officer; I think it’s going to be a very busy time!
We’re first going to be charged with creating a clinical leadership council that will include membership from all of the practices. This council will provide direction in every clinical area of cancer care.
This is a distinction of OneOncology, having our practice physicians direct the way that decisions are made within the organization. And so, we’ll have physicianled committees that will be populated by experts from the practices to direct OneOncology’s leadership team. These include a P&T committee, a technology committee, a research committee, a government affairs committee, a clinical pathways committee, and a quality and value committee.
MO: Will you continue to practice in the clinic? Also, what do you bring to the table at OneOncology in your experience as not only an oncologist, but as an administrator?
LS: I will definitely continue to practice in the clinic; in discussions with the leadership of OneOncology I felt that this was critical.
The only way you can know what’s going on at the practice level is to take care of patients yourself, so you’re arm- to-arm with the other clinicians there and you understand the issues and the substantial pressures which exist in practice today.
Over a 30-year career as a medical oncologist and a physician leader, I’ve been able to integrate a number of innovations into our own practice—now The West Cancer Center and Research Institute—with strong focus on developing clinical research efforts, including a national research network in the past.
I also have a perspective from the academic viewpoint. I served as division chief of hematology and oncology at the University of Tennessee for the last seven years, and also participated in the NCCN on the board of directors and various guideline panels.
So, this dual perspective—academic and community—is good for community oncologists. The majority of my career has been spent trying to solve problems in community oncology and advance the care of patients in the community setting.
When I trained in the late 80s, that was really the early days of community oncology, and people were coming out of academic centers with the goal and the aspiration to treat patients [as] effectively as they were being treated at a small number of academic centers.
It’s been exciting to watch that paradigm shift over the past few decades. We now see some of the best research and care coming from community practices.
MO: Was that around the time you were moving out of Memorial Sloan Kettering to go move down south?
LS: That was. I had been from New York, and it was a little scary to move to Memphis, Tenn., a place where I had only visited once, but there was great vision from my cofounders in creating a practice where clinical research was integrated from the very getgo.
And we had delivered on that promise with a very robust clinical research program as well as the innovative clinical care program.
MO: What is the rationale for community practices to band together now? What is the level of cancer care that the practices in OneOncology can offer now vs. where do you want it to end up with the creation of OneOncology?
LS: The fact that three very successful practices started talking about this a couple years ago speaks to the complexity of current cancer care, not to mention the complexity of running a small business, which has grown beyond the ability for even the larger, individually successful practices to manage on their own.
And that’s what we concluded when we formed OneOncology—we felt that, with economies of scale and intelligence, we could build resources to offer our own practices—and all the practices that are going to join us beyond the reach of any one.
We also felt that we could learn from our peers, and our motto is “We’re instituting the best practices from the best practices,” so it’s very important for us as we grow to identify the highest quality practices in any given community. Those are the practices that we want to join our partnership and the ones that will allow us to thrive in any reimbursement or political environment.
We firmly believe that value-based care will ultimately be the best model for patient centricity and for patient experience. We’re very interested in that aspect of it, but it is complicated and requires resources in order to make that transition.
MO: What does the creation of OneOncology mean for existing partnerships that individual practices have? For instance, West Clinic has partnership with the University of Tennessee. Also, how would OneOncology work with non-profits? I.e. West Clinic has partnered with Methodist Health before.
LS: A key differentiator of the OneOncology model is leaving local relationships to the practices. Each of the practices continues to control their own local market and can have the relationships they want with local partners.
In West’s case, we will enthusiastically continue to partner with the University of Tennessee in education and research. We’ve spent a long time building that platform and we want to see it prosper.
We know that in all markets, there will be other relationships, including academic relationships, which already exist or are under discussion. We believe these local relationships strengthen each of our practices, and by extension, our entire organization.
MO: Is the partnership with Methodist Health still ongoing?
LS: No, our contract terminated, and that gave us the freedom to participate as a founding member of OneOncology.
MO: Beyond OneOncology, is this trend of banding together— perhaps it’s a need—to interface and share expertise and resources also happening across the entire field?
LS: Cancer care is getting much more complex, and that’s a wonderful thing. As we better understand the biology of cancer, we’ve been able to develop better therapies and a better understanding of cancer as a large collection of small subgroups, as opposed to individual diseases that are based on the organ of origin.
This creates a complexity issue in providing optimal care, which can be difficult to manage at a community oncology level. A good part of what I plan to do is to help develop the tools and resources to allow practitioners—whether they sub-specialize like at West or if they are generalists at a small community practice to provide the highest level care beyond what is available now.
Another purpose for banding together is to continue to improve the patient experience. It’s becoming increasingly complicated for patients to navigate what is now a multidisciplinary spectrum of providers.
It’s very confusing, and they need coordinators to coordinate their care. We believe that OneOncology is the one model by which we can integrate that across practices in an efficient manner.
MO: The vision of creating provider networks isn’t new. How has bioinformatics changed since, say, the early days of US Oncology’s attempts at connecting everyone, and what can you do now that couldn’t be done before?
LS: That’s a great question. We think our partner Flatiron has been the industry leader in thinking through these questions on how to use big data in a successful way.
And that requires the development of technology tools—some of which exist today, some of which will be developed over the next few years—to allow us to practice better. Our shared data platform at OneOncology is called OneAnalytics.
OneAnalytics will have different domains—there will be operational tools, there will be administrative tools, and I will be focusing on creating the clinical analytic tools and dashboards for physicians.
So what we’d like to do is optimally create clinical decision tools, which are embedded into Flatiron OncoEMR, which answers questions for physicians in a seamless and efficient fashion so they can go about their business and see the number of patients that they need to.
Now, that’s been the promise as you’ve heard before for many years, but I really think that the technology has advanced to the point now where we can actually fulfill some of these promises.
And the building of these clinical decision support tools, I believe are in reach in the immediate future.
For example, Flatiron has already been developing clinical trials identifying technology, which allows scanning of the records, both in structured and unstructured fashion, to hone in on patients that might be eligible for particular clinical trials and the parameters around those trials.
I think that’s a remarkable use of the technology that will be able to be leveraged quickly to increase clinical trial enrollment.
MO: Before the capacity for Big Data came into existence, what did networks try to do? Have you observed instances where collaborations didn’t work out because they lacked the technological infrastructure?
LS: The technological infrastructure has improved to the point where it becomes useful in multiple directions.
We’re in the dawn of the era of artificial intelligence—a phrase that’s probably bandied around more than it needs to be—but clearly, analytics are improving rapidly, allowing us to deliver outcome measures that were once only the domain of clinical trials.
In order to deliver quality care in a value-based system, we need to understand multiple outputs from our clinical interactions in functional dashboards. We can use technology to provide resources to aid individual clinical decision-making by aggregating clinical, molecular and patient reported outcome data.
MO: What’s the business model for OneOncology and what does it take to be a member? How much does each member contribute financially and what do they get in return?
LS: On a high level, the model aligns the interests of OneOncology and the practice financially to grow the practice. So, as the practice becomes more comprehensive OneOncology grows as well.
We’re harmonizing the business practices across all of the member institutions, and we’ll be using that scale across the network to maximize efficiency in drug and supply purchasing; clinical care delivery; and the patient experience.
MO: Are you planning on adding anyone else to OneOncology?
LS: Yes. We just got started with the three founding members; we plan to add about five additional practices in 2019. Our goal by 2021 is to have approximately a thousand providers in the network.
But I want to emphasize that we’re looking at quality over quantity, we want the best practices in any given region to be partners in OneOncology. It’s not at all a land grab. We want the best, because quality is so important to our mission.
MO: The Community Oncology Alliance annual meeting is coming up: what are the top three issues that community oncology is paying attention to?
LS: I think number one in terms of community oncology issues is the cost, value and the price of cancer drugs. As you know the cost of drugs, even wonderful drugs like our immunooncology agents, are going up.
We have cellular therapy, which gives remarkable results, but at prices that, so far, institutions have not settled on a way to get reimbursement.
MO: Not to mention payers who are figuring it out.
LS: Exactly, so this is top of mind for everyone, and it translates down at the community oncology level to financial toxicity for patients. Community oncology practices have invested a great deal of money and human resources in helping patients with their financial obligations and trying to navigate a very complicated landscape of trying to get their drugs paid for.
We need to be at the table with the payers, with the manufacturers, with the hospitals, in order to create a common language around value in cancer care. That’s one major issue, I would say.
I think a very hot topic is integration of biosimilars into practice, we’re now seeing a number of biosimilars being approved in recent weeks. And for the first time figuring out how, therapeutic biosimilars in cancer care will fit in, operationally and clinically.
Another issue for community oncology is addressing the administrative burdens on clinicians that have been growing their use of third parties that require prior authorization for therapies and for imaging studies, utilization review, and step therapy which are required by certain payers—it is an enormous use of clinicians’ time that ultimately results in peer-to-peer discussions which are not useful for us.
MO: As precision medicine becomes the standard of care, what changes have you or do you continue to see in community oncology in terms of keeping up in lock step with this onco-ecosystem that is rapidly becoming more interconnected and interdependent, in many ways?
LS: I totally agree with that assessment that the cancer ecosystem is becoming more interconnected in a number of ways. The first example is interdisciplinary and multidisciplinary care.
One of the challenges in community oncology is communication with other providers that are not part of the practice. This is somewhat different from an integrated system like the traditional academic medical center.
In part, we’ll achieve this by integrating those clinicians into the practices, but we recognize that in some cases, that will not be realistic, and there have to be other technology based tools and resources to create that communication, as well as the coordination for the patients.
The other way that, as you talk about the changes in the onco-ecosystem, is becoming much more molecularly focused—I mentioned before that we’re moving from an era where everything is site and disease oriented into one where it’s more molecularly driven by abnormalities in the given pathway. And by identifying biomarkers that will stratify patients for specific therapies.
I’ve been very involved in this effort over the last five years, and our goal at OneOncology will be to provide access for patients to have comprehensive molecular profiling when that information is appropriate in care.
We plan to use OneOncology resources to help clinicians through the use of a network-wide molecular tumor board. Moreover, we will deliver access to expertise across the network that wouldn’t exist in any given practice, coupled with an enterprise-wide database to help make clinical decisions with molecular data in a timely fashion.
MO: As community practices have been consolidating, especially over the past five years, are providers moving closer toward the academic model of comprehensive cancer care? Has this been true in your experience and is that the paradigm shift in terms of thinking here?
LS: Well, for me personally it has been, that’s what in many respects I’ve been working on since I left Sloan Kettering many years ago, to provide the wonderful state-of-the-art care that is given in a comprehensive cancer center to all patients.
The interesting thing about community oncology is that you rapidly recognize that there are many, many patients who do not have the information or the resources to travel beyond their local provider, so we have to come to them. And we owe it to our patients to deliver the best possible care for them.
And today, it’s a very different landscape than it was before, which is not to denigrate in any way academic centers whose major mission is to create new knowledge, be that basic science, translational research, and educating the next generation.
Our mission that I see at OneOncology is for us to translate that information into effective treatments across the entire country and the communities we serve. And so, that’s very gratifying. When I get a patient who has to take the bus—who can barely afford transportation to the clinic—and I can get that patient onto a phase I trial.
That’s something that, to me, is the measure of success of delivering state- of-the-art care in a way that could never be possible under a system where there are only regional centers.
MO: What are the next steps for OneOncology at this point?
LS: We have plans to grow very quickly; we’re adding expertise in strategic positions in development, clinical and operational aspects of the company. From my own perspective, we’ll be focused on building a clinical research trials system for the network, developing new technology, and creating a OneOncology-wide clinical pathway system with our advisory board.
I am incredibly excited about working with the advisory board to develop ideas for community oncology that OneOncology can then make into reality for our practices.
