Outside view of Texas Cancer Clinic
There’s an old saying that goes something like this: “You can’t be all things to all people.”
Roughly three years after its founding as a filmless, paperless and wireless outpatient facility offering diagnostic imaging, oncology and surgery procedures, San Antonio-based Texas Cancer Clinic has come pretty darn close in such a short amount of time.
Much of that technological thrust and focus on patient convenience originated from radiation oncologist Bradley Prestidge, M.D., TCC’s founder, president, CEO and medical director, who launched the facility with a clear mission and intense motivation. Prestidge assumed much, if not all, of the financial risk in building TCC from the ground up, mortgaging his own financial future and that of his organization on the premise that his facility, based on a sound business plan, satisfied a community need.
In speaking with Dr. Prestidge, you can’t help but wonder how such a low-key physician with a candid and deliberate but soft-spoken conversational style could enter the competitive outpatient healthcare arena where the risks are many and the stakes are high, even though the value – to patients and personal achievement, in that order – is priceless. Dr. Prestidge’s calm and cool demeanor barely shrouds his passion for delivering high-quality patient care and pushing the envelope beyond traditional operations for an outpatient care facility.
But in October 2004, Dr. Prestidge took the plunge, created TCC and recruited a dedicated team of clinicians and administrators who have steered the facility to national renown as a multidisciplinary cancer center that incorporates diagnostic imaging, laboratory, oncology and surgery services in a single location.
Dr. Prestidge’s vision and the clinical and technological achievements inspired Outpatient Care Technology to recognize Texas Cancer Clinic with the 2007 Outpatient Excellence Award for Oncology Centers.
Tech Triumphs
Not surprisingly, a facility of TCC’s caliber is fueled by a philosophy of being state-of-the-art – whether that involves best-of-breed multiple sources or a single source – because that attracts and retains patients and clinicians. “We want to offer the best of what’s out there,” Dr. Prestidge said. “Whenever you’re buying behind the technology curve you’re going to get way behind rather quickly.” He mentioned how much it irritates him when he buys a computer and several months later a new version hits the market that renders what he bought obsolete. “We go for the best in each [clinical and technological] area but also try to get the best price.”
Much of TCC’s major imaging and oncology equipment hails from such stalwart companies as Siemens Medical Systems and Varian Medical Systems with Nucletron Corp. joining C.R. Bard on the roster last year for brachytherapy. Dr. Prestidge worked with Varian while serving in the U.S. Air Force; TCC’s radiologists preferred Siemens, particularly for PET/CT scanning. TCC also offers bone and bone mineral density scans, molecular imaging with an onsite gamma camera, three-dimensional color Doppler ultrasound largely for the prostate and Prostate Specific Antigen (PSA) testing. TCC bills itself as the first facility in the world to locate a cone-beam CT (Varian’s Acuity unit) in an operating room.
While much of TCC’s technology is linked electronically, according to Dr. Prestidge, connectivity efforts continue between some of the imaging and newer oncology units from Nucletron and Varian.
One of TCC’s fastest growing programs is in women’s healthcare – specifically in breast cancer. In fact, TCC is a staunch user of Cytyc Corp.’s MammoSite technology and represents the highest-volume individual MammoSite facility in the nation, Dr. Prestidge noted. Radiation oncologist and TCC partner Sylvia Zubyk, M.D., serves as the resident expert and heads up the specialized program. “It’s not uncommon for us to see seven or eight patients a day for treatment,” Dr. Prestidge said. TCC averages 15 to 25 patients per month that receive the full treatment regiment.
“We have 18 different surgeons in the country who come here to perform MammoSite,” he said, “so there’s no need for patients to leave the facility.”
TCC also offers a solid brachytherapy program – both low-dose and high-dose rate treatments. Dr. Prestidge indicated that he’s performed more than 2,500 prostate implants of radioactive seeds. TCC’s team remains “very active” with a number of vendors in the area of research and development, too. One example involves a functional imaging software package for oncology. A graduate medical student developed the software for black-and-white grayscale images that Varian since has improved to handle color and will be bringing that to market.
TCC also uses the ProstaScint imaging agent that helps clinicians locate and identify previously diagnosed prostate cancer. Dr. Prestidge admitted that when the technology first emerged on the market it had limited applications, but technological improvements over time (such as color), along with a dedicated clinical champion at TCC, keeps it in active use. When the color ProstaScint image is fused with the CT scan, TCC clinicians can spot the prostate-specific membrane antigen, indicative of prostate cancer cells. Prestidge also envisions the potential for breast cancer applications.
Reaching the Masses
While TCC is an independent, freestanding facility, it is affiliated with the University of Texas Health Sciences Center at San Antonio. Dr. Prestidge serves as a professor of Radiology; Amir Sadeghi, Ph.D., TCC’s chief medical physicist, serves as an assistant professor. “We do it for the teaching and the joint research with grad students,” Dr. Prestidge said. “We enjoy teaching, so [the affiliation] facilitates that, but it also adds to our credibility and legitimacy. It keeps us sharper and helps us to build visibility and a reputation in the field.” The one challenge? “There’s a little more administrative work for us,” he added.
TCC receives no funding from the university, Dr. Prestidge noted. Grad students who work at TCC either generate their own funding or tap the Southwest Cancer Foundation, which Dr. Prestidge established as a separate entity under the TCC banner. The Foundation is a 501(c)3 not-for-profit organization that funds research and community programs and services, such as cancer seminars for the public and free prostate screening. “Every penny we get [through the Foundation] goes to benefit patients,” he said.
TCC also includes the Texas Prostate Institute, which serves as the branded nucleus of the facility because it focuses on prostate cancer, and San Antonio Molecular Imaging, which represents the diagnostic imaging part of the facility and maintains separate billing. “We also wanted to give it a separate name for people with benign tumors or arthritis coming here for imaging services,” Dr. Prestidge said. “We didn’t want to scare people off that they were coming to a cancer center.”
Going Cold Turkey
TCC’s origin can be traced to one overarching motivation: flexibility.
“In short, the reason I built this clinic is that I wanted to be more nimble,” Dr. Prestidge said. “I didn’t want to have to deal with any decisions having to go before committees or get board approval to do something. I wanted flexibility in what we do. Our patients prefer that. It makes it easier for patients to get in and out, in terms of parking, navigating the building, etc., and it allows us more independence so that we can be fast to enact something. Technology is evolving so rapidly.”
Dr. Prestidge admitted that the board and committee processes in larger settings frustrated him. Even if a request was submitted to the board, it typically was considered for the next year’s budget. Prior to founding TCC, Dr. Prestidge spent six years working for a larger facility in the local metropolitan area. He joined that facility, now a competitor, after leaving the U.S. Air Force as a lieutenant colonel.
Rather than start out relatively safe financially by investing in basic technology until patient volume growth generated enough revenue to upgrade, TCC went digital and electronic from day one.
“We did it on the front end,” Dr. Prestidge noted. “I was borrowing a lot of money anyway, so what’s a few hundred thousand more? We just decided to go cold turkey. Some people have financial obstacles to deal with, but we were fortunate enough to work with a bank that allowed us to do what we did the way we did it.” He likened it to pulling off a bandage: “It’s better to do it quickly,” he quipped.
Dr. Prestidge acknowledged that opening the doors with an electronic health record system primed and ready made for a difficult transition. New hires came in a week before the opening to train on the technology. “There was some moaning and groaning for a few months, but they all came to realize the benefits over time,” he said. “In radiation oncology, a lot of people need access to the same patient charts, so you’d have to follow one chart one person at a time. Now we can have 15 people working off the same chart.”
In addition, charts aren’t lost or misplaced at the bottom of a stack of papers or damaged or destroyed, he added. Furthermore, digital imaging enables clinicians to look at images on a desktop computer from their offices. Data are backed up daily; a secondary generator stands ready to keep the place humming in the event of bad weather.
Not surprisingly, the fiscal burden to accomplish this was steep. TCC’s building, property and equipment cost about $12 million at startup, Dr. Prestidge estimated. He relied on traditional lending institutions and personal funds to get started showcasing his large prostate implant practice as an example and developing a pro forma business plan from there. Several banks expressed interest, he remembered. Without partners, Prestidge assumed a lot of debt. “But it enabled me to build the facility myself the way I wanted it,” he added. Since then he’s offered “pieces of the pie” to others. In fact, Dr. Zubyk who spearheads TCC’s growing women’s healthcare practice, is a partner, and he expects others to follow suit. “I didn’t intend to keep the whole pie to myself long-term,” he added.
“Most everything is amortized over five to seven years so we’re dealing with some pretty stiff payments,” he said. “It’s worked pretty well so far. “We’ve been able to maintain good salaries and payroll. The revenue side is pretty high but so is the expense side. It takes a huge volume of patients. We’ve been fortunate in that area. Most months we’re okay. At times we’ve spent a few months in the red but we’ve been in the black for a while now.”
TCC’s payer mix is just that – mixed. Medicare represents about 45 percent of patients with the remainder divided among managed care contracts, private payers and Medicaid. Since its inception in October 2004, TCC has performed nearly 15,500 treatments. Last year alone, TCC saw 409 patients.
Dr. Prestidge admitted that while he developed a sound business plan to launch TCC once the facility opened he concentrated more heavily on the clinical side – and rightly so, to a degree. “On the expense side, our expenses are really high,” he said. “So high some times that we spent some months in the red. I didn’t keep a lot of track of that.” He brought in a consultant that advised him to make some very difficult decisions.
“We laid off six very good people [in April] to relieve some of the pressure,” he said. The list included physicist, dosimetrist, therapist and nursing positions. “It was tough to do to our staff but we needed to do it to remain healthy and viable.” So Dr. Prestidge hired a controller that is “cracking the whip” by helping him set budgets and pay more attention to expenses.
Being PC – Patient Centric
Dr. Prestidge knows and understands the secret to patient satisfaction, and it permeates Texas Cancer Clinic – from the staff to the facility itself.
“We have a motto here,” he said matter-of-factly. “Every patient is treated like a V.I.P.” The obligatory call from a company advising the facility that its CEO is coming and should be treated as special generates smiles among the staff, according to Dr. Prestidge. “We always reply that we treat every patient that way so it’s no different than what we do normally, regardless of position, insurance or ability to pay,” he said. “We want every patient to feel like they’re the only patient we’re treating. That’s our routine. We’ll have a patient tell us once or twice a day that we have a great clinic and a great staff. I really love hearing that.”
Were it not for the sign outside, you’d be hard-pressed to call TCC as medical clinic, let alone one that specializes in cancer treatment. It doesn’t fit the stereotype – by design. Walking through the front doors of the 30,000-square-foot native Texas limestone structure places you in a glass-encased two-story atrium. The receiving area resembles a house’s great room, complete with a handcrafted bronze sculpture of four Texas red oak trees in various stages of growth, representing the cycles or seasons of life, that bookends a small waterfall. Photographic murals and oil paintings of the Texas landscape – bluebonnet fields, white cherry blossoms and manicured sculpture gardens adorn the walls in a variety of areas, including the linear accelerator and high-dose rate brachytherapy rooms. Soft music and soothing color schemes further reinforce a calming environment, which is important to patients, according to Dr. Prestidge, who credits his wife’s creativity and planning for the ambience.
“We made a real effort to do this from the beginning with the architect,” he said. “We didn’t want anything that looked and felt institutional or smelled and looked ‘sterile.’ People are coming here for reasons they would choose not to have – life-threatening illnesses and disease – so we wanted to create something that when they walked in their blood pressure dropped several points. We want them to feel comfortable and relieved.”
The staff pooled their resources and brought in a classic touch to replace the distracting television: A player grand piano. Dr. Prestidge lauds the staff for such a valuable contribution, noting that the automatic music player can be turned off to give people – patients and staff – the opportunity to play. “We’ve had both do it,” he added.
TCC’s “exceptional receptionist,” Blanche Cortez, greets all patients with a “continually smiling face” out in the open and not from behind a glass window, according to Dr. Prestidge. “She knows them all by name,” he added. “She’s the first and last face they see.”
Dr. Prestidge credited TCC’s staff of 45 for making the facility such a rewarding and successful venture, as well as a safe haven for patients. “They all are willing to reach outside their job descriptions to help each other for the sake of the patients,” he said. “It’s a group that gets along well and works well together. We share a common goal that puts us all on the same page. Patients recognize that.”
When Dr. Prestidge created TCC as a multidisciplinary cancer clinic offering imaging, oncology and surgery services under one roof he always kept the patient in mind as his motivation and strategy. “In retrospect, reimbursement was something I should have thought about more,” he laughed. “But I put myself in position of patient. What would be the best situation? At my previous job I had to send the patient out for a variety of things, such as imaging or surgery, etc. With this facility there’s a continuity of care, flow of patients and procedures. That makes it attractive to doctors to do procedures here. And it’s a patient convenience. We have 30,000 square feet. We pack a lot of breadth of what we offer.”
