Chapter 13: The Regional Care Centers and Sister Institutions
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Description
Dr. Cox gives an overview of issues involved in setting up regional care centers and sister institutions. He begins by noting that Radiation Oncology backed away from involvement in MD Anderson-Banner because of concerns that MD Anderson would have no hand in quality control for patient care. He next talks about setting up the first regional care center in Bellaire (1998/99): the regional care centers were originally established to provide radiation therapy.
Dr. Cox explains that for thirty years the treatment plans for all MD Anderson patients are created by way of a peer-review process that insures high quality care and results.
Dr. Cox next lists some other satellite centers and describes the lessons learned about recruitment and competition from within the communities. He concludes that, in general, the quality of the care centers has stood the test of time and paved the way for medical oncology and laboratory services to be offered at the sites as well. He summarizes the convenience that the care centers offer to patients. Next he describes the financial and administrative relationships between the care centers and MD Anderson. Dr. Cox then comments on the sister institutions in Orlando, Florida and Madrid, Spain, noting the importance of quality control and oversight of faculty for the success of such initiatives.
Identifier
CoxJ_03_20130423_C13
Publication Date
4-23-2013
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Beyond the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches; Fiscal Realities in Healthcare; The MD Anderson Brand, Reputation; Institutional Mission and Values; Institutional Processes; Critical Perspectives on MD Anderson; Patients; MD Anderson History
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
Let me just put an identifier on, and then we will be ready to roll. Okay—we are recording. And this is Tacey Ann Rosolowski, and today I am at the Proton Therapy Center for my third session with Dr. James Cox. Today is April 23, 2013, and the time is 10:31. So thanks Dr. Cox.
Tacey Ann Rosolowski, PhD:
And we were just talking about how today we are going to focus on your administrative roles, and you said you wanted to start at the end. So where would you like to start today?
James D. Cox, MD:
Well I want to start at the end only because of the Banner component that I don’t really think that I played any significant role in that.
Tacey Ann Rosolowski, PhD:
Okay. James Cox MD I initially had discussions with Dr. [Thomas W.] Burke [Oral History Interview] about the role that the head of radiation oncology might assume relative to Banner, but it was clear that that role which I envisioned as something similar to what we do in the regional care centers nearby was not going to be that way. It was going to be a role where we would not appoint a faculty. We would not have—I mean—ostensibly we would have control if they got into trouble, but—I mean—we would not really have control. And that has been the case. I hear almost nothing about them. Matt Callister, who is a trainee of ours, is heading the program there. He is a very, very good person. And aside from his visiting from time to time I have almost no interaction with him. Now it is possible—I think Dr. [Thomas A.] Buchholz has had more interaction after I left the division head position, but I don’t identify that.
Tacey Ann Rosolowski, PhD:
Well what was the relationship that you had envisioned and that you would have wanted to work for?
James D. Cox, MD:
Well it would be the same one that we have with the regional care centers where each of those people at—at least the radiation oncology part of the regional care centers—are faculty members of ours. And so we are responsible for evaluating them. We expect regular interactions with them, and we are in charge of the quality assurance program with them. We started that—did we ever touch on how we started the regional therapy (both speaking at once)?
Tacey Ann Rosolowski, PhD:
No. Not at all.
James D. Cox, MD:
Okay. Well, I’m sorry to be going backwards then.
Tacey Ann Rosolowski, PhD:
No—that’s quite all right.
James D. Cox, MD:
Anyhow—there was an occasional discussion of MD Anderson doing something in the community, but it was just discussion. In 1998 or 1999 I became aware of two things simultaneously. One was that a former trainee of ours whom we all held in high regard was finishing her military obligation. She was stationed in—I think in Biloxi, Mississippi, and so she was wanting to come back to the Houston area. Her husband is a dentist, and they were wanting to return to the Houston area. At the same time we became aware of a facility in Bellaire that had—for lack of any other laborious description—had fallen on hard times. They had had difficulty staffing it. It had had—I think—problems with some results in patients that were not good—not satisfactory. And they were—the person who was leading that—a physicist—was interested in selling it. So we didn’t sell it; we leased it. But that was the beginning of the entire regional care center program, and for many years the only activities in the regional care centers were radiation therapy. So when—and I was cautioned not to do that—that it was a mistake. It was a facility that had a bad reputation. It was going to tarnish the reputation of the institution, and I think by that time I had enough credibility with the senior leaders of the institution that they were willing to give us a chance to do it.
Tacey Ann Rosolowski, PhD:
What was the need at the time for the regional care centers, particularly in radiation?
James D. Cox, MD:
Well there were two needs. One is that the individual who was moving back to Houston was either going to be part of it or was going to be part of our competition.
Tacey Ann Rosolowski, PhD:
Who was this individual? James Cox. MD Elizabeth Bloom. And she is still very active—not there anymore. And she is an outstanding person.
Tacey Ann Rosolowski, PhD:
Is that B-L-U-H-M?
James D. Cox, MD:
B-L-O-O-M.
Tacey Ann Rosolowski, PhD:
Okay. Thank you.
James D. Cox, MD:
Liz took it on with enthusiasm and worked very hard, and we worked hard to bring the facility up to a presentable state to actually get new equipment put in there. In time it evolved in a way that made her happy and made us satisfied. And we were pleased with it (both speaking at once). Itt never built up to a very large number of patients, but it was successful.
Tacey Ann Rosolowski, PhD:
What was the need from the patient care end?
James D. Cox, MD:
Well, because patients often do not like to come to the Texas Medical Center. They find it confusing, intimidating, expensive, and if they can get their care closer to where they live and in a more comfortable, convenient environment as far as parking and things like that, they vastly prefer that. And it turned out that many of the patients that were treated there were actually seen in our multi-disciplinary care centers at MD Anderson—a program that involved radiation therapy was mapped out for them. And then they were given the option of being treated there. And some of them chose to be treated at the main center, and some of them chose to be treated there. And Liz did an excellent job. We did—we reviewed just as we do with every other patient—we reviewed—you know, a peer review of every patient that she treated. And she welcomed that, and it went very well. I wouldn’t say it was without any bumps, but from a professional side it was quite smooth.
Tacey Ann Rosolowski, PhD:
So is that peer review process—that is something that is done only with the development of treatment plans in the regional care centers? I am just trying to get—
James D. Cox, MD:
No. It is done with every patient treated here.
Tacey Ann Rosolowski, PhD:
With every patient (???)(inaudible)—oh wow.
James D. Cox, MD:
Every patient treated in our department has a peer review by other faculty members.
Tacey Ann Rosolowski, PhD:
Wow. Wow.
James D. Cox, MD:
And that is—I don’t know if that is unique to MD Anderson—it probably isn’t now, but it is something that has been true at MD Anderson for at least thirty years—maybe longer.
Tacey Ann Rosolowski, PhD:
Wow.
James D. Cox, MD:
And it is very valuable because suggestions are made that sometimes change the course of treatment for a patient or at least fine tune it so that subtle distinctions are picked up by various people, and recommendations are made, and they are followed through. We do it here—every patient that is treated at the Proton Center is—undergoes peer review.
Tacey Ann Rosolowski, PhD:
And that seems like a really key piece for regional and satellite care centers for quality control.
James D. Cox, MD:
It is.
Tacey Ann Rosolowski, PhD:
Yeah. Is that something—was that kind of the gold standard for you?
James D. Cox, MD:
Uh-hunh (affirmative).
Tacey Ann Rosolowski, PhD:
I mean—that was absolutely essential?
James D. Cox, MD:
Yes.
Tacey Ann Rosolowski, PhD:
Okay.
James D. Cox, MD:
Yes. And then by invitation—we did not go seeking it out in the community—by invitation we established a relationship with St. Luke’s Medical Center in the Woodlands, and then eventually I think it is CHRISTUS in Clear Lake and then I think another CHRISTUS facility in Katy. Then we had a brief stint at Fort Bend that did not work out well, and we went on to Sugar Land where we have a facility now with one and now—almost all of those places two faculty members.
Tacey Ann Rosolowski, PhD:
Now what were the various lessons you learned in each of—setting up programs in each of those places?
James D. Cox, MD:
It varied. There was generally enthusiasm on the part of the practitioners in the facilities, and they welcomed the presence of radiation therapy from MD Anderson, but there were certain things they didn’t want to do. They did not want to have our pathologists involved or our diagnostic imaging people involved, and it took a long time to get over that. For Bellaire that was no issue, but in The Woodlands it was an issue, and it was a bigger issue as we went to Fort Bend. There were competitors in the community that really, really did not like us at all—in fact—in one case one of the competitors wanted to hire the radiation oncologist that we had at the facility and offered—I seemed to recall offered her more or less $1 million. We talked about it—she said no. But—I mean, it shows the degree to which there was competition in the community and not a uniform acceptance by any means. In some cases the people in the community established a radiation therapy facility quite close by for purposes of competition. But—anyhow—the tie-in with Anderson, the peer review, the quality of what we did in general has stood the test of time, and we are proud of it. Of course, it served as the basis for going into—then having medical oncology go into the same facility that first happened at Clear Lake, and it was very successful there. Having the laboratory go in there with the—able to obtain blood products and do blood tests. And then the pathologists were able to be involved. Some of that was facilitated by the electronic medical record. As it evolved it became easier to do those things in the community with the same record keeping approach and the same standard and everything that we have here.
Tacey Ann Rosolowski, PhD:
Was that originally part of the plan to have all of those services in the regional care centers?
James D. Cox, MD:
No. I think it was only after we showed success in Bellaire that it sparked the interest of a couple people. The gynecologist who had moved into the community on their own in some ways, but soon after that, and then Dr. Burke wanted to see it develop that way. Sorry. So medical oncology was next; the last to come in were the surgeons. And now there are—I think there are surgeon jobs in all of those centers, mostly surgeons dealing with cancer of the breast. I would say there is a preponderance of treatment of cancer of the breast in those centers, but pretty much everything is treated.
Tacey Ann Rosolowski, PhD:
And what is the value for—when I was talking to Leon Leach [Oral History Interview], he was talking about the regional care centers as a strategic kind of opportunity. How do you see the regional care centers serving MD Anderson—you know (both speaking at once).
James D. Cox, MD:
Well—it’s not so simple. It helps the patients. I mean, it’s good for the patients in terms of their convenience. There are certain things that we do that it is difficult to do—that are difficult to do in the regional care centers, especially as it involves coordination of several specialties. I mean—concurrent chemotherapy and radiation therapy and surgery—it becomes more complicated. And that is especially true for cancer of the esophagus, lung, and head and neck. But the other thing is that it undoubtedly takes some patients away from MD Anderson that would otherwise come here to the main center. And the way the—I don’t know quite how to say it—the way the attribution of financial benefit from those centers to MD Anderson is recognized—is not very satisfactory from my side. When we were overseeing the radiation therapy practices in these centers, we kept separate books on that. We knew exactly how many patients were treated. We knew what the income was, we knew what the expenses were, and we had control of it. Then it was taken over by the institution, and it all flowed into a black box. And we can keep track of what happens with radiation therapy at the regional care centers, but I don’t know if any of the other disciplines do or not.
Tacey Ann Rosolowski, PhD:
So how does it work? I mean the idea is that the regional care centers—the payment—does flow back to the institution, and then the institution decides what portion of that goes back to the regional care center. And how—?
James D. Cox, MD:
Well—no—it’s—they have their budget. They have to justify anything that they want or need. They have to justify an extra nurse. They don’t have any control. The control comes from the institution, and the institution doesn’t always see the same need that is seen at the regional care center, so there can be differences of opinion about what the needs are in the regional care centers. I think most of that has become ironed out, but at the beginning that was a big problem.
Tacey Ann Rosolowski, PhD:
Were there some themes in what the administration didn’t recognize as a need? You know part of their learning curve is how to do this.
James D. Cox, MD:
They did not know what was important that was missing, and some of it may be obvious, but some of it was a hard sell to them. We could say we needed an extra clerk to have—to be there for the patients when they checked in at a certain time of day. They would say, “Well—why do you need that?” And you’d say, “Well, we need it because we need it.” And they would say, “Well, why?” And to try to document in some laborious way why you need what those people working there felt was obvious. You know—there was a disconnect, and there may still be, I just do not see it any more. I think that has become smoothed out as there has sort of been a head administrative framework developed for the regional care centers with Peter Pisters as a surgeon being the person responsible ultimately for it and a very reasonable guy, and I think one that tries very hard to do the right thing. So I think as an intermediary who has spent a lot of time—as we say—in the trenches, it is not so hard to make a case to him for the needs at one center or another as it is to somebody who has never taken care of a patient.
Tacey Ann Rosolowski, PhD:
Do you think that the regional care centers had a positive effect on MD Anderson’s public profile?
James D. Cox, MD:
Yeah, I think they have. I think they have—certainly in the greater Houston area they have and in Albuquerque where we reached out the first time outside the state. It has had a very positive effect in Albuquerque. Now there are two other what might be called regional care centers, but they were there before any of the stuff that we started in 1999. One was in Orlando; one was in Madrid. Those were governed entirely locally, in some cases with a good business sense and in some cases like Madrid with a weak approach to business. Or—you know—I mean—it seemed weak to us. Plus, we had no quality control over what they did at all. We do now a little bit more in Orlando—we have some people who go there and review patients already treated, but it is not a prospective review. We don’t have any of that in Madrid. And I don’t know to what extent we have that at Banner. I mean—maybe I should know, but I just don’t. So I dare say in my view Banner has developed more in the direction of the Orlando/Madrid model than it has the similar approach to what we have done with these regional centers around Houston, and quality control and control of the faculty—and that also means control of physics support. We think it is critical, and that is done in a consistent way in the regional care centers around Houston. That is not done in any consistent way in Madrid. Again—it is better now in Orlando as it’s evolved over the last few years. So it has all started out with the discussion of Banner because I wanted to disavow any knowledge of Banner, but then one of the administrative things that I was heavily involved with was the early years of the development of the regional care centers.
Recommended Citation
Cox, James D. MD and Rosolowski, Tacey A. PhD, "Chapter 13: The Regional Care Centers and Sister Institutions" (2013). Interview Chapters. 795.
https://openworks.mdanderson.org/mchv_interviewchapters/795
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