Cancer care is among the most resource-intensive and strategically complex service lines in modern healthcare. In response to rising cancer incidence, workforce challenges and shifting patient expectations, health systems are rethinking how and where they deliver oncology services.
From urban-adjacent freestanding hospitals to rural hub-and-spoke networks to federally funded National Cancer Institute-designated cancer centers, how organizations tackle the logistical challenge of geography has become a system-defining strategy.
Building care models with geography in mind
“There’s no question that of all the services in a hospital setting, cancer care delivery is the most expensive and, to be honest, the most lucrative of all services,” Theodoros Teknos, MD, president and scientific director of Cleveland-based University Hospitals’ Seidman Cancer Center and the Jane and Lee Seidman chair of cancer innovation, told Becker’s. “Hospitals are not thrilled about starting to address the cost of cancer care.”
Dr. Teknos said University Hospitals delivers cancer care services through a modified hub-and-spoke model. The UH Seidman Cancer Center — which is also part of the NCI-designated Case Comprehensive Cancer Center at Case Western Reserve University School of Medicine — has 120 inpatient beds and a 30-bed ICU, all connected to the UH Cleveland Medical Center. The cancer center houses medical oncology, radiation oncology and surgical oncology services.
Outside of the main campus, University Hospitals offers cancer care at 19 sites across Northeast Ohio. The system footprint is divided into regional hubs where the health system provides medical and radiation oncology. These hubs are home to community-based general oncologists and radiation oncologists while academic faculty specialists visit the hubs weekly.
“Having our academic doctors go and work side by side with our community doctors breeds a greater sense of belonging and delivers the same care at these hubs as what we deliver on the main campus,” Dr. Teknos said.
The UH community site locations are based on patient preference, regional population demographics and the specific cancers prevalent to the area.
“I previously worked at institutions where people would drive for hours just to come to the academic center. In Northeast Ohio, for whatever reason, that model just does not work for our patients. They are not willing to drive for extended periods of time, even with significant and very challenging malignancies.”
Duluth, Minn.-based Essentia Health has a similarly structured care model, spread throughout a larger geographic footprint across rural communities in North Dakota, Minnesota and Wisconsin. Like University Hospitals, Essentia delivers cancer care through a combination of central hubs and community sites.
The central hubs are located in larger communities, such as Fargo, N.D., and Duluth. These hubs offer surgical care, diagnostic procedures, radiation, chemotherapy and immunotherapy. The smaller, more rural community sites offer diagnostic imaging, chemotherapy, immunotherapy and some surgical care. The systems’ site in Ashland, Wis. — the easternmost facility — offers radiation as well.
“Our patients receive the vast majority of their care in their own communities, where they have the social support critical to navigating their cancer journey,” Lloyd Ketchum, MD, a hematologist and oncologist and division chair of cancer services at Essentia, told Becker’s. “[As] a large integrated multi-specialty care model, our clinicians utilize a common integrated medical record, which facilitates timely communication. We have found this to be the most effective strategy to provide coordinated care.”
Across the country sits Tampa, Fla.-based Moffitt Cancer Center, one of two NCI-designated comprehensive cancer centers in Florida. Home to one of the largest retiree populations in the U.S., Florida may soon be one epicenter of the healthcare industry’s aging population crisis.
“As an NCI-designated Comprehensive Cancer Center, we get patients from every county in Florida, every state within the United States and from 134 different countries,” Sarabdeep Singh, executive vice president and COO of Moffitt Cancer Center and president of Moffitt Hospital, told Becker’s. “While our goal is to reach more lives, and reach them sooner, our focus is primarily Tampa.”
Moffitt has two inpatient hospitals: one for solid tumor care and surgery and one for liquid-based malignancies that also provides cellular and immunotherapy services. Attached to both hospitals are large ambulatory care centers, where patients can receive radiation and infusion services that do not require hospital admission.
Within a 35-mile radius of the main hospitals lie Moffitt Ambulatory Centers, also called “MACs.” These centers are “one-stop-shops” for infusion, imaging and radiation services all under the same roof. Mr. Singh said the day-to-day services delivered at the MACs account for about 80% of cancer care.
“When we think about the Moffitt system as a whole, our guiding principles are that regardless of the location — whether it’s a MAC or a hospital — we have the same care delivery model everywhere,” Mr. Singh said. “That means the same quality, safety and patient experience.”
Utilizing technology to scale and decentralize cancer care
From rural North Dakota to sunny Florida, each leader said the success of their cancer care delivery models relies heavily on technological innovation. Some innovations, such as telehealth and virtual tumor boards, were established well before the COVID-19 pandemic made virtual care an industry norm.
For Essentia, Dr. Ketchum said telehealth is an “integral” part of the system’s cancer care delivery model.
“We have found that in-person visits are an excellent way to form a meaningful bond with our patients, while virtual visits and telehealth are sustainable ways to manage ongoing care in a way that minimizes the travel burden and costs for our patients,” he said.
University Hospitals and Moffitt Cancer Center are taking virtual care to the next logical step with e-consultations, ambient listening and AI-expedited administrative tasks. Not only have technological advancements helped to improve cancer care delivery, they have played a key role in solving capacity issues.
“We’ve leveraged an e-consult system whereby a nurse practitioner can do an initial assessment of a patient in house and then virtually consult with a medical oncologist elsewhere in the system who directs the team on appropriate next steps,” Dr. Teknos said. “This has also been an avenue for us to limit the number of transfers into the main hospital and allow some of those lower-acuity patients to stay in their local community hospitals.”
About 20% to 25% of University Hospitals’ cancer patients will have in-person virtual appointments, eliminating the need to drive to the hospital’s main campus in Cleveland, according to Dr. Teknos.
“Our hospital is, on average, over 90% occupied. We just frankly don’t have enough room at the inn,” he said. “We have to leverage some of our community sites for less intense oncology admissions to open capacity at our main academic hospital.”
“There are some services like survivorship or medication reconciliation that we can easily shift to telehealth,” Mr. Singh said. “Currently, about 15% of all our visits are virtual visits. That opens up physicians and APPs to see new patients or patients that need to be seen in person.”
Dr. Ketchum said the rapid integration of AI and technology will be critical to not only transforming care quality but improving workforce efficiency — a mindset shared by Mr. Singh.
“These technologies are, in a way, making life easier for our physicians, APPs, nurses and the clinical staff,” Mr. Singh said. “[They are] now able to collect medical records within minutes. It used to take weeks. When [healthcare professionals] are doing work that can be done by somebody else and is not top of the license, it leads to more turnover.”
Mr. Singh sees a direct line from using technology to increase workplace satisfaction to addressing an all-too-common industry challenge: the workforce shortage.
How the national workforce shortage hits cancer care
“A lot of it is supply and demand,” Mr. Singh said. “For certain types of roles — let’s say CT or MRI tech — there are fewer schools. The demand is a lot more than the supply coming out. We have to figure out, as a nation, how to get that supply and demand in balance.”
From nurses who either retired or left the industry completely after the pandemic, to a shortage of medical oncologists willing to work in a community setting, the healthcare force shortage hit University Hospitals hardest in 2022 and 2023, Dr. Teknos said. The system has addressed the shortage through a combination of efforts: contracting labor for specific roles such as radiation therapists, physicists and dosimetrists, utilizing locum tenens for some community sites and consolidating sites where staff was spread too thin.
For Essentia, the workforce shortage is complicated by the system’s rural footprint. The system has found some success by partnering with educational institutions to expand the local healthcare workforce.
“We have been particularly successful in the programs focused on increasing radiology and laboratory technicians, nurses and advanced practitioners,” Dr. Ketchum said. “Essentia has started an oncology pharmacist residency program, and we welcome student rotations throughout the organization both to assist in health care worker education and to serve as a recruiting tactic.”
Moffitt also has partnered with local community colleges and universities to build its own workforce pipeline in addition to establishing its own training programs for pharmacy techs, sterile processing department techs and medical assistants. The cancer center does not want to be reliant on shifting market dynamics and external forces, according to Mr. Singh.
“We offer scholarships to the graduating class and they sign up with us to work with us,” he said. “They end up loving the culture at Moffitt, so they end up staying here.”
The future of cancer care is outpatient
When deciding how to structure or restructure a cancer care delivery model, Mr. Singh, Dr. Ketchum and Dr. Teknos each offered similar advice: Center the patient. And much of centering the patient — particularly a cancer patient — means offering quality outpatient care.
“More and more care is shifting to outpatient services. Even some of our complex inpatient surgeries are outpatient surgeries now,” Mr. Singh said. “Think about what footprint you need for outpatient versus what key services you need to deliver inpatient, and then make sure you provide patient access to those services in the right setting.”
One caveat, Dr. Teknos said, is payer reimbursement, which has yet to catch up to the cancer industry’s shift to outpatient care.
“While we all agree it’s better for the patient to be closer to home and it’s better for the hospital because it increases capacity, the way the reimbursement systems are set up, it’s just not a model that works,” he said. “Hospitals, the government and our payers are going to need to work together to modify how we deliver care and how we’re paid for providing that care … while not sacrificing survival for our patients.”
“I would encourage systems to look from a patient’s perspective at the services they need and attempt to design a system where exceptional care is available locally,” Dr. Ketchum said.
That call to action is echoed by Dr. Teknos.
“The days of making people drive eight or nine hours to come to a center in a large state, or making them wait three weeks for an appointment, are long over,” he said. “Hospitals and physicians need to work together to develop strategies that provide the best care with the highest satisfaction of patients for the lowest price. That’s the definition of value.”
