A Cancer Care Model for Rural Areas

A Conversation With Laurence J. Heifetz, MD

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Laurence J. Heifetz, MD

Utilizing a high-quality secure telemedicine video connection allows patients who either cannot afford to or do not feel well enough to travel long distances the ability to stay close to home and still receive the best available care.

—Laurence J. Heifetz, MD

Rural cancer patients have long had to adjust to difficult geographic and financial barriers to access high-quality cancer care. These problems are exacerbated by today’s fiscal challenges, which have disrupted many of the small community practices that once served rural communities.

In 2006, the Tahoe Forest Cancer Center in Truckee, California, which is a remote mountain resort town, opened its doors, with the goal of focusing on patient and family fears that are common among all patients with cancer but more frightening and challenging in the rural settings. The ASCO Post recently spoke with Laurence J. Heifetz, MD, the Center’s Founder and Director.

Time for a Change

Please tell the readers a bit about your career prior to the Tahoe Forest Cancer Center.

I finished my training at MD Anderson in 1979. After that, I was in clinical practice at Cedars-Sinai Medical Center in Los Angeles up until 2003. While at Cedars-Sinai, I had been a founding partner in Tower Hematology Oncology Medical Group, a wonderful nine-doctor partnership.

When I left Cedars-Sinai, I was in my mid-fifties and decided to shake things up a bit, so I moved up to Lake Tahoe to become a ski bum and a cowboy. I tried my hand in the business of electronic medical records and promptly fell on my face. But it wasn’t a total loss because I learned a lot about the business world for about a year and a half.

A Location in Need of Cancer Services

Please describe the hospital setting where you initiated the cancer care program.

Tahoe Forest Hospital is a 25-bed critical access facility that serves a community of approximately 50,000 people living in an area of more than 4,000 square miles in the Lake Tahoe region of the Sierra Nevada mountains. The town of Truckee has a population of about 15,000, which swells considerably during high-volume tourist seasons. The hospital also has a six-bed intensive care unit, four operating rooms, an outpatient surgery center, busy labor and delivery room, and an active emergency room.

The hospital is located about 30 miles from Reno, Nevada, and 100 miles from Sacramento, California. Those distances are misleading, as the weather from November through April is harsh and snowy, causing significant traffic and safety issues.

An Ideal Rural Oncology Program

What initiated the idea to develop a rural cancer center?

At that time, there were no cancer services in Lake Tahoe; it was a blank slate. Here I was, an oncologist in town who didn’t want to work. However, after a while, the hospital and I sort of recruited each other to design an ideal rural oncology program. And since we didn’t have any legacy systems to work around, it allowed me to build it from the ground up. I insisted that it be hospital owned, as there was no way in this environment that I was going to open a private practice.

After we designed the program, we rented a small place, figuring that we would see very few patients. However, we doubled our expectations within the first 6 months and found that the hospital staff and the surrounding community valued the service.

Telemedicine as a Backup

What were some of the early challenges?

I’d never been in a solo-practitioner setting, and I needed partners from the academic oncology world as a backup. So I reached out to the three National Cancer Institute–designated cancer centers in our region: the University of California (UC) Davis, UC San Francisco, and Stanford. As it happened, UC Davis has cutting-edge technology where they have been pushing telemedicine to patients in the foothills of the Sierra Nevada mountains. So we partnered with them and created a program called the UC Davis Cancer Care Network, with four satellite facilities in addition to our Tahoe Forest Cancer Center; they include Rideout Cancer Center (Marysville), Mercy Cancer Center (Merced), and AIS Cancer Center (Bakersfield).

Virtual Tumor Board

How was the working relationship with UC Davis?

What made the relationship real were the virtual tumor boards, which began about 6 years ago. Since about 80% of malignancies comprise four cancers—lung, breast, prostate, and colorectal—if I’m going to start a program up in the middle of nowhere, it needs to have an infrastructure that knows how to treat those four cancers; then all the other clinical issues follow suit.

At UC Davis, every Monday is the gastroenterology tumor board, Tuesday is genitourinary, Wednesday is thoracic, and Thursday is breast. I had 80% of the cancers I’d be treating discussed every day at UC Davis. All we needed to do was use technology to make the communication functional.

So we built a small conference room designed to integrate multiple doctors into a communal tumor board using basic flat screen and video technology. Each physician’s image and voice can be viewed along with the diagnostic imaging studies, pathology, and PowerPoint presentation. The high-definition images and sound are transmitted through encrypted Web-based technology, ensuring both security and quality. Each site created a dedicated virtual conference room with two monitors and a video camera. One monitor is for the audiovisual transmission and can be divided so the participating members can see and speak with each other. The other monitor is for the presentation outline as well as radiology and pathology images viewed through a Web-conferencing interface.

Aside from the obvious clinical benefits of a virtual tumor board, did this collegial virtual gathering have any other perks?

Yes. The sort of closed-door attitude that exists in many academic centers opened up because we were in the inside. We were able to operate in an academic environment, so, in effect, our community patients were also UC Davis patients. And the virtual tumor board became a vital element of our rural practice. Within a few years, we were up to four doctors: three medical oncologists and a radiation oncologist.

The community built us a beautiful state-of-the-art facility, and about 40% of patients are coming from outside our catchment area. We have become a very solid program, and one reason for that is our doctors eat lunch together in the virtual tumor board conference room. We block out time together for the tumor board, even if we’re not presenting a case. It has made us feel better about the care we deliver, which in turn results in better care for our patients.


Did your positive experience with the virtual tumor boards lead to other helpful technologies that might help serve a rural community?

Yes. We’re at the top of Lake Tahoe, and we are hours away from the academic centers in our network. We also have patients living in the Sierra crest, and they would have to drive close to 2 hours to see us for follow-ups after treatment. And we’d follow these patients for years.

Since we’d become comfortable with technology ourselves, we decided to open up our own telemedicine clinics to serve our patients in their rural communities. We now operate four of these remote telemedicine clinics. Utilizing a high-quality secure telemedicine video connection allows patients who either cannot afford to or do not feel well enough to travel long distances the ability to stay close to home and still receive the best available care.

Fiscal Health

In these challenging times, has your fiscal health been an issue?

Money is always an issue, but the finances of a hospital-based cancer facility are different from those of a community practice. For one, our ability to generate revenue from our infusion therapy services is far greater than that from a community practice.

Plus, we have a very solid insurance mix: about 55% commercial, 29% Medicare, 12% Medicaid, and 4% self-pay. Our program is able to make a fairly seamless transition to an accountable care organization, whatever that may look like. We believe that we have all the elements for sustainability and growth.

The Affordable Care Act

How does your model of care fit in with the new era of oncology practice and the changes brought about by the Affordable Care Act?

Our model needs an investment from health systems. It cannot be replicated in private practice. My sense is that there is a global shift from small practices into much more organized practices like ours. And for us in the rural community, the Affordable Care Act has been a profound benefit to us as oncologists. Before its enactment, there were a tremendous amount of cancer patients without insurance. Now we can see all of our rural patients. ■

Disclosure: Dr. Heifetz reported no potential conflicts of interest.