Working Together: How to Build a Radiosurgical Center and Partnership Sandra Vermeulen, M.D. Seattle Cyberknife Center at Swedish Cancer Institute Seattle,

Working Together: Working Together: How to Build a How to Build a

Radiosurgical Center and Radiosurgical Center and PartnershipPartnership

Sandra Vermeulen, M.D.Sandra Vermeulen, M.D.

Seattle Cyberknife CenterSeattle Cyberknife Centeratat

Swedish Cancer InstituteSwedish Cancer InstituteSeattle, WASeattle, WA

Swedish Cancer Institute: Swedish Cancer Institute: BackgroundBackground

Radiation oncology providers for 7 facilities in Radiation oncology providers for 7 facilities in Puget Puget Sound area:Sound area:• Swedish Hospital at First HillSwedish Hospital at First Hill• Swedish Providence CampusSwedish Providence Campus• Seattle Prostate InstituteSeattle Prostate Institute• Northwest HospitalNorthwest Hospital• Valley Medical CenterValley Medical Center• Highline HospitalHighline Hospital• Stevens HospitalStevens Hospital

15 radiation oncologists treat 220 external 15 radiation oncologists treat 220 external beams patients per day, and perform 600+ beams patients per day, and perform 600+ brachytherapy and 300+ Gamma Knife brachytherapy and 300+ Gamma Knife procedures per yearprocedures per year

Seattle Cyberknife: Driving ForceSeattle Cyberknife: Driving Force

Private Medical Investment Group:Private Medical Investment Group:• Assessed a need in Seattle areaAssessed a need in Seattle area• Approached regional hospitals and Approached regional hospitals and

medical groupsmedical groups Intent to partner with prominent Intent to partner with prominent

neurosurgical and radiation oncology groupsneurosurgical and radiation oncology groups

• Swedish Hospital logical partner choice:Swedish Hospital logical partner choice: Largest oncology provider in the regionLargest oncology provider in the region Large neurosurgical and radiation oncology Large neurosurgical and radiation oncology

servicesservices

Swedish Radiation Oncology Swedish Radiation Oncology Physician Group: Physician Group:

Decision Process for ParticipationDecision Process for Participation Stereotactic Radiosurgery: Stereotactic Radiosurgery: is there a need?is there a need?

• Do clinical studies support hypofractionated, Do clinical studies support hypofractionated, stereotactic treatment?stereotactic treatment?

• Are there sufficient patients to justify the Are there sufficient patients to justify the device?device?

IGRT Platforms: IGRT Platforms: is the Cyberknife the best?is the Cyberknife the best?• How about Trilogy, Synergy, Tomotherapy?How about Trilogy, Synergy, Tomotherapy?

Financial Analysis: Financial Analysis: does it make sense?does it make sense?• What physician resources are required, and What physician resources are required, and

what reimbursement will be realized?what reimbursement will be realized?

Stereotactic Radiosurgery:Stereotactic Radiosurgery:Is there a need?Is there a need?

GammaKnife experience proved efficacy of GammaKnife experience proved efficacy of cranial SRS; frameless systems allow cranial SRS; frameless systems allow fractionationfractionation

For extra-cranial SRS, literature review For extra-cranial SRS, literature review showed clinical efficacy in:showed clinical efficacy in:• SpineSpine• Head and neckHead and neck• LungLung• Liver & pancreasLiver & pancreas• Previously radiated sitesPreviously radiated sites

Population of the region, and size of Swedish Population of the region, and size of Swedish network sufficiently large to justify SRS unitnetwork sufficiently large to justify SRS unit

The World of Image-guided RT:The World of Image-guided RT:Is the Cyberknife the best?Is the Cyberknife the best?

Few people really understand the differences in Few people really understand the differences in platformsplatforms• Slow dose-rate limits throughputSlow dose-rate limits throughput• Swedish Hospital had Elekta Synergy S Unit, Swedish Hospital had Elekta Synergy S Unit,

and will be clinical/research development siteand will be clinical/research development site Advantages of Cyberknife over other platforms:Advantages of Cyberknife over other platforms:

• Cyberknife only image-guided platform with Cyberknife only image-guided platform with real-time target correction capabilityreal-time target correction capability

• Only device with model to track respiratory Only device with model to track respiratory motionmotion

• Greater degree of targeting freedom Greater degree of targeting freedom theoretically yields superior dose deliverytheoretically yields superior dose delivery

CyberknifeCyberknife

Financial Analysis:Financial Analysis: Does it make sense for radiation Does it make sense for radiation

oncology group?oncology group? What did radiation oncologist using CK say?What did radiation oncologist using CK say?

• Amazing technology, excellent clinical Amazing technology, excellent clinical outcomesoutcomes

• Enormous amount of workEnormous amount of work• Reimbursement was awfulReimbursement was awful• ““Just say noJust say no”, unless additional ”, unless additional

compensation givencompensation given Financial per formas: hospital versus Financial per formas: hospital versus

professionalprofessional

Projected Hospital Revenue from CK Projected Hospital Revenue from CK CenterCenter

A successful A successful CK center CK center breaks even breaks even in year two, in year two, and can and can bring in 1-2 bring in 1-2 million/yrmillion/yr in in 4 - 5 years4 - 5 years

Professional Radiation Oncology Professional Radiation Oncology Revenue from Cyberknife SRSRevenue from Cyberknife SRS

Ratio of Ratio of revenue revenue for equal for equal workwork ext beam : CKext beam : CK 3 : 1 3 : 1

(!)(!)

Radiation Oncologists’ Radiation Oncologists’ ReimbursementReimbursement

Why so poor?Why so poor?• SRS management codes (77427, 77431) not SRS management codes (77427, 77431) not

yet reimbursed for extra-cranial treatmentsyet reimbursed for extra-cranial treatments• Radiation oncology billing historically weighted Radiation oncology billing historically weighted

heavily towards weekly management feesheavily towards weekly management fees• Treatment planning codes undervalued relative Treatment planning codes undervalued relative

to work effort requiredto work effort required• Treatment planning effort can be shifted to Treatment planning effort can be shifted to

surgeon (CPT code 61793), increasing patient surgeon (CPT code 61793), increasing patient loadload

Shift in mindset: must be comfortable Shift in mindset: must be comfortable having other disciplines participate in having other disciplines participate in contouring and planningcontouring and planning

Planning the Treatment Planning the Treatment CenterCenter

Stand-alone center?Stand-alone center?Association with existing radiation Association with existing radiation oncology facility allowsoncology facility allows• Efficiencies in office spaceEfficiencies in office space• Efficiencies in staffingEfficiencies in staffing

Physical space: hire architects Physical space: hire architects experienced in medical constructionexperienced in medical construction• Corridors need to accommodate Corridors need to accommodate

gurneys?gurneys?• Bathrooms, dirty & clean utilities, etc…Bathrooms, dirty & clean utilities, etc…

Assigning Staff:Assigning Staff:Cyberknife is Complex, New Cyberknife is Complex, New

TechnologyTechnology

• Uncertainty at every step:Uncertainty at every step: Indication for treatment are evolvingIndication for treatment are evolving Treatment protocols are not well definedTreatment protocols are not well defined Every patient requires justification with Every patient requires justification with

insurance companyinsurance company Multidisciplinary treatment requires education Multidisciplinary treatment requires education

and participation of numerous MDs and staffand participation of numerous MDs and staff Numerous steps require coordinationNumerous steps require coordination Fiducial placements – require IR – currently Fiducial placements – require IR – currently

their work is not reimbursedtheir work is not reimbursed Treatment planning processes (CT Treatment planning processes (CT

requirements, MR fusion) are unique, require requirements, MR fusion) are unique, require forethoughtforethought

StaffingStaffing

Hire motivated, smart staff, preferably Hire motivated, smart staff, preferably with experience in radiation oncologywith experience in radiation oncology• Assign a manager to oversee the projectAssign a manager to oversee the project• Physicists are expensive and hard to findPhysicists are expensive and hard to find• An organized, efficient RN or coordinator, An organized, efficient RN or coordinator,

is needed that can multi-task wellis needed that can multi-task well• Assign a technologically savvy, high-Assign a technologically savvy, high-

performing therapistperforming therapist

Plan in Advance!Plan in Advance! Have manager and staff members in Have manager and staff members in

each domain trained through Accurayeach domain trained through Accuray Have staff members (MD, physicist, RN, Have staff members (MD, physicist, RN,

therapist) proactively plan office therapist) proactively plan office requirementsrequirements• Office suppliesOffice supplies• Examining room equipment and suppliesExamining room equipment and supplies• Patient chartsPatient charts• Treatment equipmentTreatment equipment• Physics QA requirementsPhysics QA requirements

Educate Ancillary Educate Ancillary DepartmentsDepartments

Develop written CT and MR imaging Develop written CT and MR imaging protocols:protocols:• For CT: slice thickness, pitch, # images, center, For CT: slice thickness, pitch, # images, center,

patient position, contrast agentspatient position, contrast agents• For MRI: location and size of matrix, scanning For MRI: location and size of matrix, scanning

interval, sequence, contrast agentsinterval, sequence, contrast agents Interventional radiology crucial for fiducial Interventional radiology crucial for fiducial

placementplacement• Meet with MDs, radiology office manager to Meet with MDs, radiology office manager to

explain programexplain program• Reimbursement is a problem – but other Reimbursement is a problem – but other

diagnostic studies can off –set their timediagnostic studies can off –set their time• Explain detailed requirements of fiducial Explain detailed requirements of fiducial

placementplacement

InsuranceInsurance Regional Medicare intermediary initially Regional Medicare intermediary initially

not paying professional fees for extra-not paying professional fees for extra-cranial SRScranial SRS

Will this be treatment be reimbursed? Will this be treatment be reimbursed? • Meet with medical director, present Meet with medical director, present

literatureliterature Other carriers may be reluctant to pay:Other carriers may be reluctant to pay:

• Meet with medical directors in advanceMeet with medical directors in advance• Be prepared to justify treatment with Be prepared to justify treatment with

literatureliterature• Write letters of medical necessityWrite letters of medical necessity

Educate Your Referral BaseEducate Your Referral Base

Market to physicians:Market to physicians:• Relationships with referring doctorsRelationships with referring doctors• Presentations at tumor boards, grand rounds, Presentations at tumor boards, grand rounds,

etc…etc… At local hospitals and regional facilitiesAt local hospitals and regional facilities

• Open houseOpen house• Direct informational mailingsDirect informational mailings

Market to community:Market to community:• Local media – papers, televisionLocal media – papers, television• WebsiteWebsite

Clinical ConsiderationsClinical Considerations

Extra-cranial SRS is new and few Extra-cranial SRS is new and few have experiencing traininghave experiencing training

Well-established treatment Well-established treatment guidelines don’t existguidelines don’t exist

Follow-up and complication data on Follow-up and complication data on hypofractionated body SRS is hypofractionated body SRS is limitedlimited

To Determine Clinical To Determine Clinical GuidelinesGuidelines

Attend the Cyberknife Society meetingsAttend the Cyberknife Society meetings Read the literature – CK Society has a good Read the literature – CK Society has a good

reference listreference list Review radiobiologyReview radiobiology Talk with other CK Society membersTalk with other CK Society members Amount of information is overwhelming, so assign Amount of information is overwhelming, so assign

disease sites to different doctors:disease sites to different doctors:• Agree on guidelines for each disease site/stageAgree on guidelines for each disease site/stage• If there is no literature on a treatment approach, submit If there is no literature on a treatment approach, submit

formal protocol to your hospital IRBformal protocol to your hospital IRB Consider gathering data on dosing, toxicity, and Consider gathering data on dosing, toxicity, and

clinical outcomes to guide future treatmentsclinical outcomes to guide future treatments

SummarySummary Realize enormous work effort required to Realize enormous work effort required to

start center and treat CK patientsstart center and treat CK patients MDs should evaluate in advance the MDs should evaluate in advance the

financial implications of participatingfinancial implications of participating Hire best available staff, preferably with Hire best available staff, preferably with

radiation oncology experienceradiation oncology experience Get trained and organized in advanceGet trained and organized in advance Pro-active involvement & education of:Pro-active involvement & education of:

• Insurance companiesInsurance companies• Ancillary services (intervention radiology)Ancillary services (intervention radiology)

Uncharted clinical waters: physicians do Uncharted clinical waters: physicians do your homework, and cautiously write your homework, and cautiously write protocols/guidelines.protocols/guidelines.

ConclusionConclusion

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