‘You’d have to live under a rock to not know what some of these new therapies are costing’

Cancer care is quickly expanding to meet growing demand. The American Society of Clinical Oncology reports that 18% of cancer care practices opened a new site last year, while 9% merged or created a joint venture. One recent entry is the Miami Cancer Institute, which opened January 2017. Located on the Baptist Hospital campus, the $400 million, 370,000-square-foot building houses a 250,000-square-foot outpatient clinical services practice, a dedicated cancer research facility and the first proton therapy center in South Florida. The center consolidated 13 different business units under one roof and created a startup that has introduced a hybrid cancer center to the region. The goal, CEO said, is to offer the best of a community hospital setting and

Dr. Michael Zinner marry it to a traditional academic cancer center—Memorial Sloan Kettering in New York. Modern Healthcare hospital operations reporter Alex Kacik recently spoke with Zinner about the institute and its mission. The following is an edited transcript.

MH: How are you doing operationally and financially?

Zinner: In terms of unique patient visits a day, we’ve had an increase of 20% to 25% over when we first opened. We’re seeing about 1,000 patients a day. Originally, when we were being designed and built and set our financial forecast, we fully expected not to be profitable in the first couple of years. So far this fiscal year, we’ve beaten budget by a significant amount. With respect to what we’ve done in terms of recruitment—and that has a lot to do with the programs and the people, as well as the finances—we are way ahead of our projections.

MH: Is recruitment and retainment of staff an issue for you?

Zinner: When we opened, we inherited approximately 20 or 25 legacy physicians. Those were the doctors in the community who came on board full time. Since we began operations, we’ve recruited an additional 50 physicians who have come from all over the country. So we’ve increased our professional staff dramatically. We’ve more than doubled it. We also grew the number of regular staff from what originally was around 600 to 700 to now about 1,200 full-time employees.

MH: Why was it important to partner with an academic medical center?

Zinner: I’ve had the opportunity to work in many parts of the country and up until now my entire career has been with academic institutions. And I’ve seen over that period of time a number of affiliations or partnerships that were frankly nothing more than branding. This is not the case here.

When we established our relationship with Memorial Sloan Kettering, we went through telephone books’ worth of checklists to line up our own resources and capabilities with theirs, our own standards of care with theirs. So we took, for example, six disease groups of the most common cancers and literally went through checklists of how we would work up a patient, how we would treat a patient, what kind of operation we would do, how the pathology would be evaluated and what the post-op care would look like.

We meet with our Memorial Sloan Kettering colleagues on a very regular basis. I was just in New York with a team of 10 or 12 of my docs last month. We have regular telephone conferences and talk about disease programs on a monthly basis as well as the traditional, if you will, tumor board kind of activities.

MH: Cancer care increasingly is at the core of many recent partnerships and mergers. What role does it play in hospital operations?

Zinner: Unfortunately, cancer is one of the diseases of the aging population. Florida is one of the fastest-growing states in the U.S. and a large part of that is the retiring-age population. So in terms of what we’re going to do, we need to stay up to date. We need to stay up on the latest technology because cancer is going to be a major part of healthcare, certainly in South Florida, but probably all over the U.S. Where that goes is sort of hard to predict. I think systems will get larger. I think there will be fewer and fewer standalone facilities that are able

to weather the storm of decreasing reimbursement and increasing need. Fortunately, I feel we’re one of the systems that can do that.

MH: Cancer care is also very expensive. How do you reconcile that with valuebased care?

Zinner: If I knew the answer to that I’d win the Nobel Prize. You’d have to live under a rock to not know what some of these new therapies, particularly the biologics, are costing the system. The good news is they work. The bad news is they’re incredibly expensive. How to reconcile those two is—I won’t say it’s a daily challenge for me— but it’s a regular challenge for me.

Both the lay and professional press have successfully told the population that we have a new generation of therapies that really works, but it really is expensive. So it’s up to all of us to figure out what’s the most appropriate care, when to do it, and when not to do it. I know that’s going to sound overly simplistic, but we’ve got to figure out both sides of that equation.

MH: What role do you see for precision medicine in cancer care?

Zinner: It will help us decide what we should and what we should not do, so we embrace it 100%. Research presented at the recent ASCO meetings about the breast cancer trial suggested that we’re probably overtreating a lot of women with early breast cancer. Think about how important that is. Not just shorter treatments, but in some cases, no treatments—other than aromatase inhibitors. The better we get at precision medicine, the better we’re going to be at who to treat and who not to treat. So we are 100% embracing all of the precision medicine genomics and genetic testing that we’re doing, because it will help us say, “Nope. We should not treat you,” or “Yes, we should treat you,” even if it’s with expensive drugs.

MH: But is it sustainable?

Zinner: Yes. First of all, the testing is getting less expensive. Still not cheap, but the testing is getting less expensive. It’s not quite a commodity yet, but it’s not going to be too long from now that precision medicine testing will become a commodity. And who can do it fastest, cheapest, best and most accurately will be a survivor. And we’ll use that to be able to make the decisions I talked about. We recognize that right now there’s a cost associated with it, but there’s also a better outcome associated with it.

MH: What about proton therapy? Is that a financially viable model?

Zinner: I believe it’s the exact same thing as precision medicine. We have to decide who it should and should not be used for. And I can make some negative comments about how it’s been overused in certain areas and underused in other areas. We’ve made some decisions here about appropriate use. For example, it’s very clearly indicated in children because you definitely want to decrease the collateral damage. We have as high or a higher percentage of our patients under beam that are children than any other place in the country.

Secondly, there are certain tumor types where we don’t have the data yet, but we’re getting the data on where it’s most appropriate—where you don’t want to deliver radiation to the surrounding areas because it will cause damage. Those are in certain brain tumors, and certain spinal tumors, and there are certain tumors that are near the heart where you don’t want to radiate the heart, because those patients have higher chances of having a heart disease later in life. Those are more of the areas that we’re focusing on, for who to treat and who not to treat.

MH: Please explain what MR Linac service is.

Zinner: This is fascinating to me, in part, because I’m a surgeon, so I knew nothing about radiation therapy. It’s basically a CAT scan, shoot a picture, shoot another picture, shoot another picture, and line up the radiation beam with that. What the MR Linac does is, it follows the tumor in real time. For example, for a liver tumor that we would ordinarily use radiation therapy to burn out of the liver, if we use traditional therapy we’d have to have kind of a normal rim of tissue that we’d have to burn to make sure that when the patient’s breathing, we still got all the tumor in it. But if you’re breathing in and out, your tumor’s moving every time you breath. With the MR Linac, we can actually look in real time where the tumor is, so the beam is on when it’s in focus and off when it’s out of focus. And that means we have more and higher accuracy for potential kill, and it involves less of the normal tissue to lower the kinds of tissue damage around the area that you don’t want to hurt.

“It’s up to all of us to figure out what’s the most appropriate care, when to do it and when not to do it.”

MH: What’s the institute’s strategy moving forward?

Zinner: We’ve done the traditional layout of capital for all the traditional therapies, including radiation therapy. We’re still in the recruiting mode. I’d say I’ve probably got another 10 or 15 positions I want to add over the next 12 to 24 months.

We are getting more heavily into cellular manipulation and immunotherapies. We want to do that and we want to do that right. It’s expensive and the capital associated with that has been allocated, but we’re going to do that probably, again, over the next 12 to 24 months.

With respect to the other aspects, we are reaching out regionally to partner locally with other hospitals in South Florida to, again, deliver routine care in those facilities and high-end care at our main facility. ●