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Florida is a highly competitive market for oncology. During the last two decades, it has become more so, with the large influx of retirees and their familiarity with managed care and the Medicare Advantage plans, and with the pleasant climate, which draws oncologists as well as retirees from other parts of the country.
One of the state's most successful group practices is the Integrated Community Oncology Network (ICON). Headquartered in Jacksonville, ICON has thrived on this competition and continues to do so. What began as a modest private organization now has practice area extending from Brunswick, Georgia, all the way south to Ocala. The Journal of Oncology Practice asked ICON President Thomas Marsland, MD, to describe the vision and management that fueled this growth.
According to Dr Marsland, the story begins in the mid-1990s, when a half-dozen medical oncology practices were operating in the Jacksonville area. He was a partner in one of them. Three of these practices were recruited to join American Oncology Resources (AOR), the precursor to US Oncology. Combined, these three groups included about 15 medical oncologists, and at the time, they offered only medical oncology and chemotherapy administration. Marsland was one of the medical oncologists.
“We stayed with US Oncology [AOR] for about 5 years,” said Dr. Marsland, and then parted company for two fundamental reasons. One was return on investment. “We thought we could do a better job on our own,” said Dr. Marsland.
The other reason was somewhat more personal. A large radiation oncology group was practicing in the area, and US Oncology was contemplating a competitive offering.
“We didn't want to do that, for lots of reasons,” said Dr Marsland. The reasons were both practical and personal. The existing radiation oncology group was large, with about 15 doctors, and it intersected with US Oncology in patient care, as AOR's cancer centers used the group for radiation.
“Plus, we were close personal friends,” said Marsland. “We traveled together; our kids grew up together. So perhaps another reason to get out of US Oncology was to take that central authority out of the equation, and free us to make our own arrangements.”
In March, 2005, the chemotherapy and medical oncologists joined the radiation oncologists to form a new practice, to be called the Integrated Community Oncology Network.
“We came together to expand services, actually a little along the lines of US Oncology,” said Dr Marsland. “But clearly, imaging was one of the major driving forces bringing us together.”
Marsland also observed that drug revenues had been decreasing for years, and it was obvious that new revenue streams were needed. Imaging seemed like a natural fit. The merger brought the total to approximately 40 physicians, and it has since grown to 48, including a few physicians who practice part time.
“We have 26 to 27 medical oncologists, close to 20 radiation oncologists, and two dedicated radiologists for [computed tomography] and [positron-emission tomography] evaluation,” said Dr Marsland. “We also have physician's assistants and nurse practitioners, and use them to help free up the doctor's time.”
Meanwhile, ICON continues to look for new opportunity, and is currently developing an in-house pharmacy for oral prescription drugs. “We have been working on that for 5 months, and I think last month was the first time we actually broke into the black,” said Dr Marsland.
The network is also pursuing clinical research. “We've always been very active in clinical research,” says Marsland. “It became part of our practice in the old AOR/US Oncology practice days, when we were one of their top five accruers of patients to clinical trials. We do cooperative group studies at NSABP, RTOG, and ECOG [the National Surgical Adjuvant Breast and Bowel Project, Radiation Therapy Oncology Group, and Eastern Cooperative Oncology Group]; we do industry-sponsored trials; and we recently signed a contract to be part of the Sarah Cannon Network. We put about 250 patients a year on clinical trials, and want to expand that,” he says, noting that there has been discussion about beginning a phase I program to get drugs earlier, and make them available to the patients.
To control its drug aquisition costs, ICON is involved with the International Oncology Network (ION), a Group Purchasing Organization (GPO) headquartered in Baltimore, Maryland. “We get as good a price on drugs as there is anywhere in the country,” says Marsland.
ICON is also looking into expanding laboratory services, and is negotiating for equipment to measure circulating tumor cells.
The practice has a six-person board of directors consisting of three radiation and three medical oncologists, one of the latter being Dr Marsland. The board meets monthly and discusses day-to-day business as well as larger strategic issues. Strategic retreats are held for major issues such as expanding into surgery and rehabilitation. These are open to all of the practice partners. Meanwhile, a professional management team helps with the day-to-day work, profit and loss statement generation, and regulatory issues.
Marsland's prescription for management is simple: “You talk to everybody about everything.”
“There's a lot of compromise, give, and take,” he is quick to add. “Sometimes we have conflicts.” When they do, he says, it can usually be traced to the current modular governance structure, which is based on the three original practices that came together.
“If we open a new center, who's going to staff it, who's going to get the cost, who's going to get the expense?” he asks rhetorically. “My personal goal over time would be to get away from the modules, and make it all more integrated.”
Especially important, according to Dr. Marsland, is to keep the younger physicians involved. “We (the board) are in our 50s, and how do we involve leadership among the younger doctors, so they are vested in this whole thing?” He does not want the board to be perceived as controlling or dictatorial. “That's something we're struggling with, especially with the ones who remember when there were only 12 of us and it was more democratic and consensus-driven. But if you're going to have a practice of 50 or 60 physicians, you just can't have them all steering the boat.”
During the week, Dr Marsland still takes his own calls, and works about every fourth or fifth weekend. “It's easier that way, because you know your own patients.” He travels frequently, and his partners understand the value of this to the business.
In all of this, JOP wondered what Dr Marsland was most proud of: “Bringing the radiation and medical oncology groups together to form a 50-doctor practice. We can do just about anything, and I don't think there's any other practice in the country that can do this much. We have a gamma knife, a cyber knife, two global PET-CT scanners, we have our own cyclotron, make our own FDG, and we've just got this circulating tumor cell machine. We've got a very active clinical research program, we provide good patient care, and we have a couple social workers. We try really hard not to send Medicare patients to the hospital…I think it's exciting. We have opportunities to do things the average practice just can't do.”