Forget about humming "The Gambler" and knowing when to hold ‘em and when to fold ‘em. For Zimba, it’s all about teaching clinical and operational colleagues to role play a game he calls competitive friction. The name of the game is that everyone should compete for West Penn’s business, whether they’re existing or prospective contract holders.

"Even if we may favor one vendor we don’t want to tip our hand to get them to act differently," Zimba said. "We need to play our hand correctly. I can be in a game with crap in my hand, but I must play it like I have four-of-a-kind in my hand. Getting people around the table to believe you have it is how the game is played. Bluffing is a big part of it."

On the surface, Zimba’s contract negotiating and sourcing strategies may seem like a recreational romp but don’t be fooled by the bravado. He considers it serious business. And competitive friction is a winning strategy that recruits for the same team the clinician who has an allegiance to one vendor and another who’s open to therapeutic equivalents.

"For some, that’s hard," he said. "Nobody wants to pay more than they should – even the one with the tremendous allegiance. So I really play on that. We have limited funds, so how are we going to get what you want? You don’t try to change what they want but you get them what they need at a good price. They change [attitudes] when they believe they have options. If I create options for the end user I’ve done them a better favor."

Such gamesmanship isn’t limited to oncology devices and equipment applications but it’s certainly reliable and valuable to the technology selection and acquisition process, according to Zimba.

Equipping a hospital oncology department or an outpatient cancer treatment center with radiation therapy technology may stop well short of rocket science but seems as close to it as purchasing diagnostic imaging or high-end surgical equipment. Unless you do your homework up front, Zimba contends. The homework includes understanding the clinical variations and qualitative differences in radiation therapy applications but not necessarily what they do, the total cost of ownership for the technology, constructing the room to contain and operate the technology, servicing the technology and the interfaces of that technology in terms of the total package and its integration into existing facility infrastructure.

"One may be the most expensive technology but the least to construct," Zimba noted. "Another may be the least expensive but the most [expensive] to construct." And you have to remember that all of them will deliver therapy that will deliver results, he added.

While clinicians may have their own opinions about a particular therapy or technology, it’s more important that they have an open ear to different strategies and tactics, according to Zimba.

"You can’t always buy what’s the newest on the market today," he said. "Some companies are leaders in the long-term development of technology and will eventually create what needs to be done."

Zimba and his team recently worked with West Penn’s oncology group to replace a 15-year-old radiation therapy system by Varian Medical Systems at the main hospital. West Penn’s oncology group comprises the hospital’s oncology department and eight freestanding oncology centers with close ties to Siemens Medical Systems. The hospital-based oncologist favored the radiation therapy system by TomoTherapy Inc. At the onset, both factions of the group expressed concern about whether West Penn wanted to grow its cancer treatment program or encourage the hospital to compete with the outpatient centers in a zero-sum game, Zimba noted.

"Originally, the oncologists thought I was screwing up with their grand plan," he said. "I gave them examples of doing what they want but at more competitive price. In this particular instance the organization didn’t have enough money so they had an impetus to play the game. Administration suggested that oncologists work with the contracting division to source this product."

Based on the requests for proposals received by the few key players in the market, the radiation therapy equipment West Penn needed hovered around $4.1 million in total costs. Using the competitive friction strategy, however, West Penn was able to slice about $500,000 off the total cost of ownership for five years, including construction, service and warranty, from the company the oncologist wanted – TomoTherapy. Zimba admitted that they’re still paying $1 million more than West Penn originally wanted to spend but a faster installation period (three to four months) means they’ll be able to use the equipment earlier and generate revenue more quickly.

Susan Levine, DVM, Ph.D., vice president, technology assessment and editor in chief, Hayes Inc., (Lansdale, PA) indicated that the success of such decisions hinge on the technology assessment process.

"Technology assessment is really critical and it doesn’t get done as much as it should," she said. "Sometimes there isn’t time or expertise of the people available. With technology assessment, hopefully you make better choices. Your decisions are more defensible and transparent. You show a clear, logical path in the decision-making process. You have to be convinced yourself, not relying on opinion or fancy marketing material."

It’s also important to look at the growth potential of the technology, particularly as it relates to "fusion" technologies capable of imaging and treating the patient simultaneously, according to Jan Dragotta, clinical director of radiation oncology at CentraState Medical Center (Freehold, NJ). "Radiation oncology departments can transition readily to paperless as so much of the technology is computer driven," she added. Dragotta’s department recently invested in four-dimensional treatment machines, management systems and imagers from Varian and Elekta Inc.’s IMPAC Medical Systems Inc. unit.

Choosing relationships

Some facilities may ensnarl themselves in a debate between a multi-vendor best-of-breed approach and a single-vendor relationship. Depending on the facility’s capabilities and preferences, either way can work so long as the pros and cons are understood.

"Best of breed allows for personal preference," Dragotta noted. "My experience has shown no one manufacturer excels in all modalities. A single vendor overall may cost less. A vendor providing all technologies usually makes attractive deals to outfit a new or renovated department. Ideally, a single vendor deal would provide better support to assure the department is completely outfitted."

Zimba links the decision to whatever value can be derived from the relationship, such as maintenance and training for some applications across multiple sites. At West Penn, one part of the oncology group developed a relationship with Siemens that offers value to them. "But some companies may not want to create those kinds of relationships with everybody," he added. "They’d rather simply make a transaction."

Levine attributes the decision to the expertise of the hospital staff. "If you’re mixing and matching equipment you need people who can maintain and service all of those machines. If you don’t have that capability you could be in trouble," she said. "Using a single vendor for most equipment might be better, especially for the big ticket items. Still, it’s good to look at questions about all vendors. One vendor means a loss of control, yes. But it really goes back to the strengths of the hospital."

"The biggest advantage of a single vendor is that data flows and integration should generally be easier but not foolproof though," said Robert Maliff, associate director of ECRI’s Health Systems Group (Plymouth Meeting, PA). Service and upgrades tend to be easier with a single vendor, too. "The downside is that you may lose out on a novel approach to treatment," he added.

Competing with outpatient facilities

Even though the majority of radiation therapy procedures are performed on an outpatient basis, hospitals shouldn’t toss in the towel. For certain procedures, hospital-based reimbursement is favorable enough to make it well worth the hospital’s investment to effectively equip a department, according to Dragotta, particularly if the hospital is located in a competitive market.

The more obvious solution is for the hospital to jump into the outpatient market or joint venture with an outpatient facility, Levine noted.

"Hospitals will always offer more strength, depth and breadth of services," she said. "Patients often come in with multiple diseases – say, cancer plus heart disease plus diabetes. But there’s definitely a need for outpatient services. The best way to compete is to offer comparable and convenient services – pleasant atmosphere, ample and accessible parking. Clinics may have less overhead, which is a trade-off, and they may skim off the easier patients. Collaboration may be more effective. I used to work at Mayo Clinic in Rochester, MN, and we worked a lot with other clinics. Some eventually became part of the Mayo family. But it enabled us to attract new and more patients."

Bill Herman, vice president and general manager of cancer center services at US Oncology Inc., a Houston-based healthcare services network dedicated to cancer treatment and research, agreed.

"We believe there are great opportunities for collaboration between freestanding cancer centers and hospitals," Herman said. "Each has their unique advantages, but together, they can create a powerful force in increasing patient access to treatment options.

"For example, the hospitals are inherently suited to meet in-patient needs, such as surgery (likely a singular event). However, the freestanding cancer centers can offer high quality, advanced care and an improved patient experience for the ongoing care that is received on an outpatient basis, such as the ability to go to one convenient location near their home where they can access the radiation and/or chemotherapy treatments they need. Parking is near the front door and often, the patient can also obtain their other prescriptions from an on-site pharmacy. Also, the patient’s records are in one location, along with their doctors who can then collaborate on the patients care." US Oncology works with more than 900 physicians practicing in about 460 locations, including 85 outpatient cancer centers in 32 states.

Because much of radiation oncology care is outpatient-based a freestanding center is an ideal solution for patient ease of access, according Maliff. Of course, a full-service outpatient center may not be that different from the full-service hospital department. However, many freestanding facilities contain only linear accelerators, he added, with simulation and treatment planning located somewhere else.

Still, Paul G. Goetowski, M.D., with the Carolina Regional Cancer Center (Myrtle Beach, SC) contends that a freestanding cancer center can outperform a hospital, based on his experience. "A hospital has multiple departments to juggle," he said. "Some that generate revenue (like radiation oncology) which have to subsidize other departments that always lose money (like emergency). If you have a freestanding center which is operated as a professional practice, like ours, rather than simply a business, then you often can generate enough cash flow to have better service or different technology than a public hospital. It depends so much on the quality and style of management on both sides."

Stumbling blocks to success

Materials managers face a host of challenges and misconceptions when they decide to help oncologists equip their departments or facilities. Many of them are fundamental and start from the very beginning.

"One thing is being able to understand what all the technologies do," Levine said. "It can be hard for even a technologist. A lot of these technologies are high-cost big-ticket items. Understanding the clinical ramifications of not having a certain technology and its effect on patient care can be important. You also have to consider radiation safety versus advanced treatment planning."

Another involves price. The lowest price does not always translate into the best choice, Dragotta insisted. "Without understanding usage, it is difficult to understand how a choice that cost more initially may be ultimately most cost effective," she said.

A facility also has to decide when and who will start the construction or renovation project to make way for new oncology equipment, Zimba added.

Herman emphasized that facilities should focus on total cost of ownership. "It’s not just the acquisition costs, but with technology changing about every 18 months and with new clinical findings occurring at an equally rapid rate, the importance of ongoing training is clearly critical," he said. "Consider the transformation of the training of the radiation therapists. They may come into the practice with a two-year degree and without radiology experience, but today’s technology requires an increased knowledge of imaging. Training is critical and it should be an ongoing budget item – not just in the first year."

Dwelling on the purchase cost rather than the ongoing operational expense is a bad idea, according to Goetowski. "How much manpower, downtime, custom proprietary versus off-the-shelf parts, service contracts add to the expense of running a center can quickly overpower the capital costs of starting the center, and make a ‘smart’ purchase look pretty dumb pretty quickly," he said. "Also, you have to have technical staff that can use what you buy, and well-trained dosimetrists, physicists and therapists don’t come cheap."

Financing, selecting appropriate levels of technology and staffing, as well as trying to balance a thorough assessment of demand, technology solutions and operations comprise other key concerns, Maliff noted. Furthermore, it’s not easy to install any system in any setting. "Linear accelerators have tremendous room requirements with different manufacturers and their models all having different reqs," he said.

"Probably the biggest mistake we see is when practices don’t balance their sources of information," Herman said, including gathering all possible information from manufacturers, conducting peer conversations and site visits, reading published clinical literature and attending user group or training sessions. Such a balanced viewpoint, both technological and clinical, of what the technology can bring to the practice helps clinicians develop "a realistic expectation of utilization," he said.

Tips for success

For a hospital to make the right decision on which oncology equipment to acquire means the materials managers have to balance the needs and wants of the clinicians with the education and promotion of the vendors.

"[Materials managers] may not know what these high-cost technologies do and why they matter so they need to have confidence that the clinical research work has been done and that the clinicians have found clinical evidence to back up the use of this equipment," Levine said. "Materials managers should ask for this data. Clinical need and efficacy questions should be answered first. The power structure doesn’t allow for materials managers to go in and determine what to do. You want to avoid the ‘this would be nice to have’ mentality and do the work."

Dragotta insisted that materials managers include and rely on the end users, such as the clinicians and department heads, for guidance. "It is a very technologically complex field with few vendors. Everyone needs to be comfortable with these treatment modalities," she said. "Sales for these vendors can be convincing, but may not provide a complete picture of the needs for any particular product line. Vendors can be, however, an invaluable resource for information gathering about standards of care and best practices within the industry as well as the direction investigations regarding new techniques are going."

Dragotta offered additional useful tips. "Do your due diligence. Talk to others using the products within your area or in similar institutional settings. Purchase for growth. The field is constantly changing. Include ancillary departments in planning, particularly IT and facilities. Vendors may not inform you of what you need from your end. For example, electrical or mechanical upgrades to existing facilities. Those incidentals can add up."

It’s also important to remember that radiation oncology equipment tends to last at least 7 to 10 years. That’s why the vendor or vendors chosen must be "true partners," Maliff noted. "Get them to do some innovative things in support, training or research activities," he said. "Professional services for installation, interfacing and integration of all components should be negotiated."

US Oncology requires manufacturers to satisfy four rules before the company will be considered for a contract, Herman said. First is connectivity. "The technology must be able to ‘plug and play’ within the company’s platform." Second is service and support capabilities. "They must have an extensive service infrastructure to support our network practices across the country." Third is multi-generational product planning. "We must be able to see and understand the future of their technology so that we can avoid the pitfalls of early obsolescence," he said. "This is critical due to today’s rapid technology development cycles." Fourth is that the technology must be clinically acceptable, enable "ease of use" and meet product specifications.

"If a technology manufacturer cannot meet these requirements, then we do not consider them for contracts," Herman said. "There are many new and emerging technologies that may offer great promise, but the size of the investment for these types of technologies require a disciplined approach for the best returns on that investment." For evaluations, US Oncology relies on a technology committee comprising radiation oncologists, physicists, dosimetrists and radiation therapists and its in-house staff of clinicians and former technology executives. HPN