Maximizing the value of a breast center

The Breast 19 (2010) 253e259

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The Breast journal homepage: www.elsevier.com/brst

Original Article

Maximizing the value of a breast center Mickey Goldman*, Dan Chang Insight Oncology, Inc, 71-780 San Jacinto Drive, Suite. C-2, Rancho Mirage, CA e 92270, United States

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 18 April 2010

This article focuses on the value and benefit of a Breast Center to an organization by identifying the best ways to maximize their contribution in order to create and sustain a financially viable, clinically respected and community-oriented Breast Center. The goal of the Breast Center is to ultimately benefit the community and the hospital’s Comprehensive Cancer Program as a whole. The value propositions are divided into three areas that have positive impacts to the program and hospital, collectively. These value propositions are:

Keywords: Breast center Value Financial Quality Integration

1. Financial Value e identified values of the Breast Center that contribute to the bottom linedor Return on Investment (ROI)dof the Cancer Program. 2. Clinical Quality Values e identified values of the Breast Center that improve the quality of care and outcomes of the patients. 3. Intangibles Values e identified values of the Breast Center that connect to the community and women that is invaluable to the Cancer Program.

Ó 2010 Elsevier Ltd. All rights reserved.

Introduction Breast cancer is one of the most common forms of cancer diagnosed among women, second only to skin cancer. One out of every seven women will be affected by breast cancer in their lifetime. In 2009, it is estimated that more than 192,000 women will be diagnosed with invasive breast cancer.1 Despite the rise in innovative technologies over the past thirty years combined with the increase in consumer awareness for this disease, breast cancer screening programs have actually seen a decrease in mammography screening rates in the recent years.2 Freestanding imaging centers increased in numbers by 20% in 20013 but have begun to struggle as they fight to maximize their low-profit margins. Their growth waned to 4% in 2007. Hospitals have also been abandoning their breast imaging business identifying significant financial losses as the primary reason while physicians show less enthusiasm for the specialty.4 Meanwhile, it is projected that the need and demand for mammography will increase as the baby boom generation retires and enters the age at which breast cancer is most prevalent. These trends related to breast cancer highlight the challenges facing

* Corresponding author. Tel.: þ1 (760) 834 8595, þ1 (760) 409 4205(mobile). E-mail address: [email protected] (M. Goldman). 0960-9776/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2010.03.019

Breast Centers and hospitals and the need to create integrated cancer programs that fully utilize the value of the Breast Center. Types of breast centers The National Consortium of Breast Centers identifies five different Breast Center types: Screening, Diagnostic, Clinical, Breast Cancer Treatment, and Comprehensive Breast Cancer Treatment. Table 1 shows how these centers differ in the services provided. Background According to the National Breast Cancer Coalition, approximately 3 million women in the U.S today are living with breast cancer, a million of who do not yet know they have the disease. Men are also at risk of developing breast cancer but account for 1% of all breast cancer cases.1 In 1975 the incidence of breast cancer was 107 per 100,000 for white women and 94 per 100,000 for black women. Thirty years later in 2005, the number of new cases per year had risen to 126 per 100,000 for white women and 114 per 100,000 for black women.5 (Fig. 1) Breast cancer holds societal implications and can be very impactful to the social context of the community. In addition to the harsh clinical effects of the treatment of breast cancer, survivors of

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Table 1 Breast center type. Service Component

Screening

Diagnostic

Clinical

Treatment

Comprehensive

Outreach-Education Imaging Needle Biopsy Pathology Surgical Care Plastic Surgery Radiation Therapy Medical Oncology Rehabilitation High Risk Clinic Research

X X O O O O O O O O M

X X X X O O O O O O M

X M X X X M M M M M M

X X X X X X X X X M M

X X X X X X X X X X X

Key: Source: http://www.breastcare.org/BCTypes/centertypes.html.2 X service must be provided, M service may be provided, O service is not expected.

the disease also face alarming trends in regards to life outside of the hospital, including insurance, employment and other economic issues. Obtaining and retaining health insurance with a history of breast cancer can be challenging especially if one relies on their employer for coverage. Some women stop working altogether after being treated for breast cancer. And those who continue to work afterwards face alarming statistics. Studies have shown that survivors of breast cancer experience a modest but statistically significant 5e15% decline in earnings.6 Other economic issues such as paying for co-pays, prescription drugs, and medical devices and supplies compound the societal impact of breast cancer.

Financial value Integrated Breast Centers contribute significantly to the hospitals bottom line. Direct revenues that come from screening and diagnostic services provide modest gains while indirect revenues via surgery, radiation therapy, chemotherapy and other ancillary services contribute significant profit margins. Screening services generate high volumes of patients directing breast cancer cases. Treatment of these patients with high profit margin services in an integrated fashion is known as the downstream effect. Thus, the best way to maximize the financial value of the Breast Center is to strengthen its direct line of revenue via screening and diagnosis, increase patient volume, and effectively capture the downstream effect.

Maximizing the value of a breast center Direct revenues The value of a Breast Center can be identified as qualities and aspects that have a positive impact on the Cancer program or the hospital as a whole in either a financial, clinical or an otherwise intangible community related way.

Having a dedicated Breast Center equipped with state of the art screening and diagnostic equipment is necessary to produce high quality results and optimize direct revenues. Direct revenues come

Fig. 1. Breast cancer incidence and mortality. Source: SEER Cancer Statistics Review Fast Stats, 1975 e 2005.5

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Fig. 2. Unbundling breast center finances. Source: The Advisory Board, Oncology Roundtable, Breast Cancer Center Of Excellence, 2005, Page 8.7

from its screening and diagnostic services. Typical revenue for a mammography visit yields approximately $118 per patient (Fig. 2). Nearly 30% of patients who receive a mammogram go on to get a diagnostic workup. Having the ability to offer full service diagnostics in one location adds to the quality, efficiency of care and financial performance of the breast center. Volume The combination of advanced technology that maximizes the value of breast screening and diagnostic tests coupled with the entrance of the “baby boomer” generation, who are at the age of greatest risk to breast cancer, has made the Breast Center one of the key drivers in volume of oncology patients. In the next 15 years, the number of women between the ages of 65 and 84 years old is expected to increase by 50%.5 And because the incidence of breast cancer is highest within this age range, the services of the Breast Center to screen and diagnose these cases will be of high demand. Seventy-nine (79%) percent of women forty or older received mammograms in the past two years compared to 56% ten years ago8 (Fig. 3). In addition to the high demand for screening services from the growing number of cases expected in the coming decades, breast cancer awareness programs will also increase volume as campaigns

Fig. 3. Percentage of women  40 with recent mammogram. Source: FDA, www.fda. gov/cdrh/mammography.8

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Fig. 4. Contribution to hospital revenue. Source: The Advisory Board, Oncology Roundtable, Breast Cancer Center Of Excellence, 2005, Page 7.7

for breast cancer awareness tap into the emotional significance of this disease as a women’s health issue. Breast cancer awareness is a growing trend among many established organizations and continues to inform the public of the impact of supporting the cause and the potential benefits of screenings and early detection. And although the current leading cause of death in U.S. women is heart disease, more money is raised per year for breast cancer research because of the emotional connection breast cancer activists are able to create with the general public.9 Cancer programs are also starting to understand the potential business development opportunities to steer additional volume to breast centers by coordinating care and having a specialized physician available. National studies have shown an expansion of geographical market share after the implementation of a dedicated breast surgeon to a hospital that previously only housed general surgeons. In a specific case, 18% of breast surgery volumes came from a new market previously untapped by the hospital.7 As breast centers drive volume, it also shifts patient volume proving that patients and physicians prefer care that is coordinated and efficient.

radiation therapy, and 28% of imaging7 (Fig. 4). Furthermore, after unbundling the different service lines, outpatient procedures and imaging are key revenue drivers making up 26% and 42.9%, respectively, of total revenue (Fig. 2). While imaging drives the revenue, the most profitable services are outpatient surgery and radiation therapy, which typically yield $1799 and $1978 in revenue per patient, (Fig. 2). Capturing downstream revenues from breast imaging is an especially significant point as it highlights the importance of having a screening center that acts as a feeder to other service lines that are more profitable and the hospital providing those high quality services in collaboration with their medical staff. This idea of service line integration has proven to dramatically increase the efficiency in capturing revenue as well as stifling costs. In her article advocating for breast health reform and breast center development, Marie M. La Fargue provides a comprehensive approach to service line integration highlighting the guidelines (Table 2) for ensuring optimal success.2 In Table 3, the application of service line integration demonstrates an example of the efficiency this strategic process provides for a medical center.

Downstream revenue Patients found to have breast cancer will feed different services lines such as imaging, surgery, radiation therapy and chemotherapy. A modest increase in screening mammogram volume can lead to a multimillion-dollar increase in revenue for the hospital from diagnostic procedures, radiation therapy, chemotherapy and surgery. Recent studies show that the financial contribution of breast cancer services on hospital-based oncology revenue is significant. In a study analyzing the future of Breast Cancer Strategy, The Advisory Board finds that breast cancer services typically contribute 3% to inpatient oncology revenue and 21% of total outpatient revenue, which includes 12% of chemotherapy, 16% of

Clinical value In the past decade, breast cancer screening technology has made substantial improvements in image quality and the efficiency of cancer detection well beyond the standard x-ray capabilities used before. Breast centers today offer various forms of screening, diagnostic and treatment planning imaging modalities from breast MRI to Positron Emission Tomography (PET), to full-field digital mammography (FFDM). The clinical value a Breast Center provides the ability to harness these new technologies to detect cancer more accurately and efficiently. Coupled with the growing public

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Table 2 Service line integration checklist Data Gathering/Market Intelligence

Key Encounters/Observations

Critical Work Group Assessments and Deliverables

Patient satisfaction score

Pre-treatment planning meetings and/or Tumor Boards Cancer Committee

C-suite vision and strategy alignment

Clinical outcomes and service delivery dashboards; MQSA audit review statistics Physician satisfaction score

Grand rounds/CME lectures

Profitability/payer mix

IRB Office

Branding/image/preference research

Tumor Registry

Market share and other Office of Statewide Health Planning and Development (OSHPD) data Accreditation standingdMQSA, The Joint Commission, BICOE, ACR for other breast imaging modalities, ACOSNAPBC, and NCBC certification other breast imaging modalities, ACOS NAPBC, and NCBC certification

Marketing and Business Development Medical Staff Service

Coding and downstream revenue analysis with Finance and Decision Support Services Vision and strategy alignment with all key groups of cliniciansdpathologist, radiologists, general surgeons, radiation oncologists, plastic and reconstructive surgeons, nurses and other allied health professionals Medical Director role review and clearly defined expectations and job description with associated performance threshold measurements Breast health services dashboard development with indicators that integrate the entire continuum of care Assessment of breast services staff essential job functions for opportunities for shared growth expansion of roles and productivity Enhance the accreditation process for breast servicesdSICOE. MQSA, Joint Commission ACR for Mammography, Breast Ultrasound, Stereotactic Biopsy, and Radiation Oncology

Accrediation standing-MQSAÔ, The Joint Commission, ACR Breast Imaging Center of Excellence; BICOEÔ, American College of Surgeons National Accrediation Program for Breast Centers/NAPBCÔ, National Consortium of Breast Centers National Quality Measures for Breast Centers: NOMBCÔ, National Quality Measures for Breast Centers, certifications in the following areas: (1) Certified Quality Breast Center of Excellence; (2) Certified Quality Breast Center; and (3) Certified Participant in the NQMBC Program. Source: La Fargue, Marie M., “A Breast Center Development Fable: Could Service Line Integration Stimulate the Happily Ever After for Breast Health Reform,” Seminars in Breast Disease, 2008, Elsevier Inc.2

awareness, these technologies have the potential to improve the chances of patient survival through early detection of the disease. According to the American Cancer Society, most physicians feel that early detection tests for breast cancer save many thousands of lives each year and that many more lives could be saved if even more women and their healthcare providers took advantage of these tests. This clinical value is undeniably one of the most significant contributions of the Breast Center and can be maximized by integrating the Breast Center with the multidisciplinary approach of the Comprehensive Cancer Program. Better clinical outcomes come from integrated breast programs. The nature of a multidisciplinary approach fosters teamwork and communication, which in return reduces errors and maximizes efficiencies. Multidisciplinary care also typically produces better clinical outcomes. This remains consistent with a dedicated program for breast cancer care. Clinical outcomes data proves that having dedicated breast experts demonstrate improved outcomes with fewer complications and recurrences compared to nonspecialists10 (Fig. 5). With Comprehensive Breast Centers focused on providing a cohesive one-stop shop for screening, diagnosis and treatment of breast cancer, the quality of life for the patient along with the positive clinical outcomes increases dramatically. Comprehensive Breast Centers typically focus on spreading awareness to boost screening volumes which in turn provide the opportunity to diagnose cancer at an earlier stage, allowing for treatment to be less invasive and more successful due to its early detection.

Promoting this information to the community and educating referring physicians that patients will receive exceptional care at an integrated Breast Center can best maximize the clinical value of a Breast Center. Intangibles There are also benefits derived from a Breast Center that are immeasurable. Through outreach and educational efforts, Breast Centers create a community value that affects both its residents and the hospital positively. This “halo effect” builds trust within the community that ultimately connects to women who are the healthcare decision makers in the family. Maximizing this value involves developing trusting relationships with the women of the family who in turn will ultimately view the hospital as their primary source of care in times of need. Community value Significant benefit is derived from a Breast Center that cannot be valued monetarily, such as the positive image a Breast Center builds for the hospital and its Cancer Center. Dedicated Breast Centers

Table 3 Snapshot of breast center profitability. XYZ Medical Center Outpatients with Mammography Charges Direct

Indirect Total Cost Expected Reimbursement

402,360 1,562,243

263,615 666,175 1,407,427 (before) 723,096 2,285,339 3426,409 (after)

Source: La Fargue, Marie M., “A Breast Center Development Fable: Could Service Line Integration Stimulate the Happily Ever After for Breast Health Reform,” Seminars in Breast Disease, 2008, Elsevier Inc.2

Fig. 5. Source: Kingsmore D, et al., “Why Does Specialist Treatment of Breast Cancer Improve Survival? The Role of Surgical Management,” British Journal of Cancer, 2004.10

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typically provide community, patient and physician education. Outreach services provide free screenings to the low-income and medically underserved and spread goodwill and expand community access to such necessary services. Breast Centers also set up community benefit programs, speaker programs and other events designed to meet the specific needs of targeted populations, expand access, provide education, offer financial support, and stay connected and in touch with the community, all of which fosters a sense of compassion for their patients. By offering programs to its members in the community with a focus on diversity, collaboration and access, Breast Centers are then able to forge a bond invaluable to its overall mission. Taking advantage of the community value of the Breast Center involves finding ways to maximize the success and improvement of these community programs. This includes providing a diverse set of programs that connects to different aspects of the population from the underserved, to ethnically diverse groups, to women’s health issues. Collaborative efforts with community organizations further help in understanding the needs of the patient community. Some of the most successful programs benefit from hundreds of local community sponsors that all provide insight into how to connect with the community.

Connecting with the healthcare decision maker Women are the drivers in making healthcare decisions for their family. A Breast Center, through its screening programs, connects with women on a very personal level. By establishing and maintaining this trusting relationship, the Breast Center can create a strong bond between the family’s healthcare needs and all services offered by the hospital. The importance of women’s health transcends any gender or racial designation. A healthy woman impacts the lives of everyone because of the role of the woman in a household. Thus, the value that a Breast Center places on the woman is significant and meaningful. A successful Breast Center will not only respond to issues of breast health, but will also create a synergy of women’s

services that focuses on breast health and incorporates all other women’s health issues. To accomplish the goal of providing a model of care that encompasses all of women’s health needs requires the integration and multidisciplinary approach of a Comprehensive Cancer Center that takes all the values a Breast Center provides and maximizes them to their fullest potential. Only then can a program such as a Breast Center utilize its benefits at maximum capacity.

The need for integration Effective diagnosis and treatment of breast diseases require a coordinated interaction amongst various specialties throughout the hospital, which include: radiology, surgery, medical and radiation oncology, pathology, psychosocial services, rehab, and nursing. Traditional treatments of breast cancer have consisted of different specialist working in isolation leaving the patient feeling disjointed and lacking continuity. Comprehensive Breast Centers employ the philosophy of coordination and continuity by integrating all specialties into a multidisciplinary team approach. This methodology, as shown on Fig. 6, enhances communication and provides cohesion amongst all those involved creating a synergy that is palpable to the patient, ultimately producing better clinical outcomes. According to the National Coalition for Cancer Survivorship, the number of cancer survivors has increased from three million to twelve million over the past 25 years. The growth of this population is largely due to the process in the treatment of cancer and the formation of Comprehensive Cancer Programs. Excluding the actual medical and symptomatic realities of the disease, some of the most stressful aspects of breast cancer are the sequence of office visits and time that elapses between initial diagnosis and treatment. Cancer patients are often subjected to a series of tests and appointments with various specialists at different locations. A comprehensive program connects all the different specialists involved and synchronizes appointments and tests to create a continuous model of care that eases the life of the patient.

Fig. 6. Integration and coordination.

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Conclusion

References

The value of a Breast Center has been categorized into three sections. The financial value added to the institution, superior clinical outcomes, and the intangible benefits that create a halo effect around the institution in the eyes of the community and the primary healthcare decision maker in the family, the woman. A hospital must organize itself in a way to maximize the benefit of all of these opportunities. This includes creating a high quality breast center, establishing a multidisciplinary team of breast experts who work in an integrated fashion, state of the art technology and integrating the breast center with a comprehensive cancer center to streamline ongoing care and follow-up surveillance. This approach will provide your organization with the significant benefits outlined here and also create a positive physician integration strategy for hospitals and their oncology specialists.

1. American Cancer Society. Cancer facts and figures 2009. Atlanta, GA: American Cancer Society; 2009. 2. La Fargue MM. A breast center development fable: could service line integration stimulate the happily ever after for breast health reform? Semin Breast Dis 2008;11(3):116e23. doi:10.1053/j.sembd.2009.04.002. 3. Sandrick K. Outpatient imaging centers grow by adding new services. Diagn Imaging 2008;30(12):1e2. 4. American Cancer Society and California Cancer Registry. California facts and figures. American Cancer Society and California Cancer Registry; 2009. 5. SEER cancer Statistics Review, 1975e2005: fast stats. Bethesda, MD: National Cancer Institute. Available at, http://seer.cancer.gov/csr/1975_2005/; 2008 [accessed 25.11.2009]. 6. Syse A, Tretli S, Kravdal O. Cancer’s impact on employment and earnings e a population-based study from Norway. J Cancer Surviv 2008;2:149e58. 7. The Advisory Board. Oncology roundtable, breast cancer center of excellence. The Advisory Board; 2005. 8. FDA statistics. Available at, http://www.fda.gov/cdrh/mammography [accessed 16.11.09]. 9. Ericksen J. Taking charge of breast cancer. Berkeley: UC Press; 2008. 206. 10. Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancer improve survival? the role of surgical management. Br J Cancer 2004;90: 1920e5.

Conflicts of interest statement None declared.