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October 2013
Quest for Rational Care
By Jenni Walker

     When Paul Franz of Carolinas HealthCare System (CHS), a vast organization of 30-plus hospitals and 600 care locations, first interviewed Derek Raghavan in late 2010 to potentially head up the multimillion dollar cancer center they were building, he had no idea the precocious doctor would turn the tables on him.

     Raghavan was one of a handful of prominent oncology program administrators that CHS had carefully culled as being up for the task. Raghavan was at the time director of the Cleveland Clinic Taussig Cancer Center where, after seven years, he had raised its ranking by U.S. News & World Report from No. 46 to No.9. He wasn’t looking to change jobs.

     Yet, by his own admission, he had started thinking more globally about ways to get patients into clinical trials, removing barriers to access to care, eliminating perverse incentives that influence treatments that doctors recommend.

     Raghavan came for the meeting anyway. It was during the conversation that he had the audacity to remark to Franz: “I am not really interested in the job you’re offering, because I am not really interested in building a regional cancer center. But,” he continued, “if you want to ramp it up—to let me build you a world-class cancer center, one of the top centers internationally and also that serves the Carolinas—I would be interested in doing that.”

     In short, Raghavan was drawn to the opportunity to start with a blank slate and design the foundation and the systems on top of that, as he describes it, “building a rational cancer care system on an empty lot, based on bioinformatics tying together hospitals and outpatient clinics.”

     Franz tells it, “Derek’s eyes lit up with the opportunity, and, as you know, he can process things at 300 miles per hour. Immediately, our vision, which we thought was dramatic, Derek made 10 times bigger,” spewing “Here’s what you can do with this…here’s what you can develop here…here’s an opportunity to do this…”

     Raghavan continued to think through the implications of the Carolinas challenge, grasping some immediately and others “during shower time.” When CHS determined they wanted him to guide this mega-adventure, he accepted, starting as president of the Levine Cancer Institute in April 2011.

 

Building It Rationally

     Carolinas Healthcare System had been looking for the next big thing. They had successfully embraced cardiovascular services, which Franz describes as typical of most health systems in that they represented the best market share opportunity and were the most profitable service line.

     In 2007, they decided oncology made sense. They were already treating a considerable number (10,000) of new patients a year. Competition was weak— there were excellent cancer centers along the system’s boundaries, but not in its core area around Charlotte. And at the time, changes in reimbursement were weakening physician-owned, office-based practices, potentially making doctors more willing to join hospitals.

     In 2009, a CHS consultant confirmed that their patient volume was enormous and their timing was good for building a regional cancer center. Estimates for building a regional cancer center in the Charlotte area came up to about $250 million over a decade; however, given the needs of the entire system, CHS executives doubled that number.

     Construction began, made possible in part by a generous $20 million donation from philanthropists Sandra and Leon Levine of the Levine Foundation, along with tremendous support from CHS and the community. The center was to be specifically designed as a cancer care center “without walls,” the coordinating center for a series of integrated cancer care centers throughout the system.

     Opened in August 2012 and boasting 171,000 square feet of space in a stunning six-story architectural magnum opus, the facility certainly appeases those concerned about the aesthetics of the Charlotte landscape, but more importantly provides nine cancer clinics, infusion therapy, radiation therapy, palliative care and a Phase I clinical trials center, all under one roof.

     In addition to containing the most progressive clinical modalities and equipment to treat rare and complex cases, it also serves as the springboard for a clinical trials and research division and community education initiatives.

     It is this level of dedication and commitment to improving the patient experience and outcome that makes the Levine Cancer Institute so unique and on the path to becoming an internationally lauded facility. These themes were also considered a top priority in the physical design of this new space.

     It includes an Image Boutique on site, complete with wigs, prosthetics and other recommended treatment supplements. The Image Boutique goes a long way to make patients feel and look their best while dealing with some of the physical challenges overcoming cancer can bring.

     The Blumenthal Infusion Center, named in honor of the Blumenthal family who have supported cancer care at Carolinas Medical Center for years, is located on the fourth floor of the new building featuring more than 80 infusion chairs in a peaceful and caring environment. There are also mind/body wellness programs and a healing rooftop garden available for patients.

     “Cancer care includes much more than just diagnosis and treatment of the disease itself,” explains Raghavan. “Cancer affects every aspect of a patients’ life and one of the goals of Levine Cancer Institute is to broaden the scope of cancer research, prevention, treatment and survivorship to reflect the full impact of cancer on our patients and community.”

     So far, the system has spent $50 million in building the cancer center and another $20 million on renovations and recruitment.

 

A Man with a Vision

     Raghavan is a medical oncologist who came to the U.S. from Australia in 1991, which may be why he sees our health care system with the clarity of an outsider. His reputation is built largely on years of service on the FDA Oncologic Drugs Advisory Committee (ODAC), where he became known as “the sort of guy you don’t want to match wits with.”

     In one cancer journal, they say “His precisely aimed, lethal, Australian-accented remarks had, on more than one occasion, trashed cooperative groups, pharmaceutical companies, and the National Cancer Institute (NCI) itself.

     They are on point in describing his temperament: “Raghavan’s brand of humor would be better described as aggressive truth-telling. His delivery if perfectly deadpan. Indignation seems to affect his face like a dose of Botox. It’s possible that the guy laughs, but this has not been observed in public. Raghavan claims to be unable to retrain himself when an absurdity materializes within striking distance.”

     Indeed, Raghavan unabashedly admits, “I am deficient in self-control,” proud that he “says stuff most people would rather not.”

     Even though his tenure on the ODAC committee ended long ago, the agency keeps inviting him to return. “One of the most attractive features about ODAC is it doesn’t have lawyers on it, so we can actually think about patient welfare.”

     In selecting Dr. Raghavan CHS graced Charlotte with one of the most brilliant minds in the world of cancer care.

 

Building a Coalition

     One of Raghavan’s first challenges in accepting the position at Levine Cancer Institute, was to reach out and engage the medical community to identify common interests and areas of cooperation and collaboration. That included recruiting key physicians to complement clinical strengths in Charlotte and beyond.

     Raghavan reached out to the local community. Physicians like Kathryn Mileham of the Mecklenburg Medical Group graciously accepted because, “They gave us an opportunity to mold our future. Each physician had an opportunity to say, ‘I have an interest in a particular cancer,’ or ‘I prefer to maintain my community focus…without having to subspecialize.’

     “We were given the opportunity and support to make those decisions on our own. Without being unwillingly channeled toward a particular focus, it is easy to maintain the energy and the excitement and the drive to succeed in providing all aspects of excellent patient care.”

     Raghavan also reached out to academic stars, willing to leave prestigious academic institutions to join the team. With a broad, world-view approach to treating cancer, Raghavan never thinks small.

     “When we started, I made a list of 50 of the top cancer physicians and researchers that I wanted working at our center. I was able to recruit 40 of them,” says Raghavan. The feat is a testament to his tenacity for achieving the best for patients; a quality that perfectly complements the Institute’s vision of “changing the course of cancer care.”

     Since he joined the staff two years ago, Raghavan has recruited 82 specialists altogether. Mike Tarwater, CEO of CHS, attests to Raghavan as a “skilled recruiter, bringing some of the nation’s most gifted and talented oncologists to our region.”

     Raghavan says, “I basically wanted to bring in the very brightest people who weren’t jerks.”

     In truth, he wasn’t kidding and simply demonstrating his frank and often unintentionally humorous candor that is such a large part of his charm and unassuming persona. Perhaps most importantly, his belief that “the team trumps the individual” is both genuine and a mandate for his staff.

 

Raghavan’s Health Care Initiatives

 

     •Access to and Consistency of Quality Care. “We want to make access to cancer care easier for all,” says Raghavan. “Our physicians work with each patient to determine a personalized care plan based on their needs.” Using symmetrical access to care with a system-wide approach, Raghavan and his team utilize a de-centralized model of treatment and support which provides state-of-the-art care distributed evenly.

     That’s a hot button for Raghavan who explains, “The quality of care should use an integrated approach and be the same where ever you go in our system. A patient in Greensboro should have the same standard of care available as a patient in Fort Mill, or in Charlotte.” To that end, the Institute has a large and growing network of 12 charter member hospitals to ensure quality cancer care is delivered at each facility across the Carolinas.

 

     •Patient Participation and Navigation. Raghavan also puts a high premium on patient participation in treatment plans and outcome goals and is not satisfied to let them sit idly by as others make decisions for them. “I believe in treating cancer by engaging patients as part of the team so they know they can influence the outcome,” he says.

     The Institute offers patient navigators who play a vital role in helping patients find specific cancer services including different types of clinical trials and cancer registries, as well as clinical and support therapies, such as clinical modalities, grief consultation and survivorship, and palliative care. Working in tandem they help guide cancer patients and their families through their journey of healing and transition oncology care to the most appropriate location for the patient.

 

     •Caring for the Underserved. Of great interest to Raghavan and something very influential in his decision to accept the position at CHS was his profound commitment to treating the underserved. Of course that’s a polite term for the poor and those who can’t afford or don’t have access to health care. It is significant to note that in 2012, CHS spent approximately $1 billion in treating these populations.

     The breakdown includes $250 million in Medicare contracts, $250 million in Medicaid, and $500 million in caring for the indigent—money they will not recover. It’s one of the things Raghavan is most proud and he admits feeling frustrated over how little attention it gets in the media.

     “Doing altruistic work should be celebrated, and I am proud of the fact we look after this population,” he says. “The fact that we are prepared as a system to lose this amount of money from our bottom line is a testament to our commitment to providing care for everyone.”

 

     •Value Not Volume. As the cost of health care continues to be a top concern and albatross for the country, Raghavan was very attracted to what he characterizes as some of the “top, thoughtful” business minds at CHS who understand the need to get health care costs under control. He notes, “We are committed to helping people get better but we should be sensible in how we invest in treating patients and spend our dollars.”

     One cost-saving measure has been to consider the best treatment in terms of patient billing. If there are three treatments with equivalent efficiency and side effects, they will choose the least expensive option.

     Raghavan is also focused on moving patient care to a model based on outcomes rather than treatment options. “The algorithm has changed. It’s about value, not volume,” he explains. “Don’t choose a particular treatment because you can. Do it because it’s good medicine. We need to set constraints and be thoughtful.”

     Regarding the Institute as a microcosm of the nation’s complex health care system, Raghavan believes the underlying problems with health care can be fixed. Overall, he believes that people have some unrealistic expectations for health, government can’t afford the care we want, what consumers ask for is expensive, and that nobody wants to pay for health care. As a result, it creates monumental challenges for the federal and state governments to plan for the future.

     “We can’t make changes in health care simply by writing them down,” says Raghavan. “Sometimes we see people making prophetic statements with no skin in the game.”

 

Continuing to Innovate

     CHS now delivers cancer care to over 14,000 new patients a year. In less than three years the Levine Cancer Institute has literally changed the course of cancer and eliminated many of the natural barriers to top-quality care, such as distance to clinical and research sites, cultural barriers and patient access.

     From the technological spectrum, the Institute utilizes one of the most advanced wireless systems in the country. Joining forces with Accenture, it developed an app that connects with patients electronically so they don’t have to leave their home. Medical teams can also conference with other hospitals within the Carolinas HealthCare System and physicians have all clinical trials and a system of pathways for cancer care guidelines available for instant download.

     The Institute uses a holistic approach to cancer care and cancer survivorship. Part of the approach also includes financial and nutrition counseling sessions, support groups and wellness programs. Doctors and clinical teams also continue work with patients who have been cured and are dealing with the after-effects of their treatments so they can develop algorithms in that group.

     The Institute has also launched a Levine Oncology Program for Seniors at Mercy Hospital and at Stanly Regional Medical Center and are piloting the Flying Squad—a home-visit program to treat those who are remote and not well enough to visit the hospital.

     Amazing advancements in research are being made including first-in-human trials and complex cancer. Researchers have implemented unique programs to better track outcomes, drive efficiency, move research from bench to bedside quickly, and establish more accountable cancer care. Currently, there is a 12-bed monitoring unit in Charlotte and they are expanding to other sites.

     In addition, Phase II trials are underway, and a bone marrow transplant unit and a palliative medicine unit are being built. “I have had the opportunity to lift the game and increase the interplay between research and trials,” comments Raghavan.

     While many in the Charlotte region don’t even realize it, our community is now home to one of the premier cancer treatment centers in the entire world in the Levine Cancer Institute. It houses the largest single institution cancer research databases and is accredited by the American College of Surgeons Commission on Cancer and by the National Accreditation Program of Breast Centers.

     Dr. Derek Raghavan and his team are leading us into a new era of innovative, intelligent, and thoughtful cancer treatments and care. He says generously of the Institute, “What I saw here was a well-organized hospital system with the resources and seriousness of purpose to create a world-class institute. Alongside that was their preparedness to bring in national stars and their ability to provide adequate support for clinical trials and patient navigation—I just leveraged the vision they had.”

     Reflecting back, he says, “It felt like a perfect fit. And it has been more rewarding than I could have imagined.”

 

 

Photo by Fenix Foto

Jenni Walker is a Greater Charlotte Biz freelance writer.
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