Fisher Discusses Turnaround at Fox Chase

A year ago, Fox Chase Cancer Center lost money: $17 million.

In 2015, the losses have stopped, and an $8 million operating profit is projected.

Fox Chase is part of the Temple University Health System, which is rebuilding its cancer services around the venerable center.

“We’re in an interesting time at Fox Chase—because as I look ahead to the future of health care and accountable care coming, I think it’s unlikely if many, if any, of the freestanding cancer centers will be able to stand by themselves in that kind of arrangement,” Richard Fisher said to The Cancer Letter. “So right now, we’re a fascinating model that’s going to be looked at by our colleagues to see how it works.”

Here are the changes that occurred over the nearly two years since Richard Fisher was named director, president and CEO at Fox Chase:

• New patient appointments went up by 14 percent and online registrations by 41 percent after Fox Chase started to offer new patients next-business-day appointments.
• The number of surgical patients went up by 15 percent over last fiscal year, and is on pace to exceed 5,000 cases in the operating room in FY15.
• The number of grants awarded by NIH to Fox Chase went up by 50 percent over last year.
• An internal competitive grant process was launched, using the NIH peer-review to award grants for interdisciplinary translational cancer research projects, under the leadership of the new deputy cancer center director for translational research, Wafik El-Deiry.

How did this turnaround occur?

The Cancer Letter asked Fisher to talk about the turnaround, and describe his plans for Fox Chase in the competitive Philadelphia-area market. Fisher spoke with Paul Goldberg, editor and publisher of The Cancer Letter.

Paul Goldberg: All cancer centers are different from each other. When you’ve seen one cancer center you’ve seen one cancer center. What is unique about Fox Chase?

Richard Fisher: I certainly agree with you in that regard. Fox Chase is a wonderful, fascinating place. As you know, it was one of the original four places, when I trained, where you could get cancer training. And it had a tremendous history as a freestanding cancer center, of which there are only about 11 in the country now.

It had tremendous research activity in the past—and what really still stands out today, whenever I talk to people, is that anyone who comes in for care comes into Fox Chase feels this culture of incredible patient care that is a cornerstone of the organization. And I get letters every day of the week from patients and families telling me how wonderful the doctors are, the nurses are, and the support they get. So there’s a real culture of caring that goes throughout the organization.

There’s been a very strong basic science presence over the years, resulting in all kinds of awards and things. And there’s been a real control and prevention program, led largely by Paul Engstrom for many years, who is very well known in the field in that regard.

We’re in an interesting time at Fox Chase—because as I look ahead to the future of health care and accountable care coming, I think it’s unlikely if many, if any, of the freestanding cancer centers will be able to stand by themselves in that kind of arrangement. So right now we’re a fascinating model that’s going to be looked at by our colleagues to see how it works.

We’re merged into a health system here, and I suppose we’re the first in the group to do that. But it’s an interesting experiment. It’s working very well at the moment. And I think people are going to be looking forward to that in the future.

What do you think went wrong before you came in at Fox Chase?

RF: The major problem that organizations all have is good periods and bad periods; they go through cycles.

The difficult cycle before me was largely precipitated by fiscal events. There was some construction of major facilities and buildings that was highly leveraged and protected by swaps. And, unfortunately, that happened right before the market went bad. Therefore, there was enormous strain on the fiscal resources of the organization.

That period ended when Temple University Health System came in and acquired Fox Chase. We became a wholly owned subsidiary of Temple Health, one of the family members of the corporations within Temple Health, and they retired that debt, refinanced it, and got us back to where we could start thinking about the future.

Being a part of a large health system, and you’re not alone in this, is it fair say that you are a freestanding cancer center?

RF: Well, it’s a complicated story. We call ourselves a hybrid right now. We are still a corporate entity; I’m the president and CEO. We have our own CFO, we have our own board, we have our own finances, we have our own faculty, our own tenure system, etc.—but we are part of Temple Health, and within Temple Health, we now have the opportunity to move into their community and we’re going to be the brand for all of Temple Health cancer.

So Fox Chase Cancer Center-Temple Health will be beyond the scope of just the original Fox Chase, but will be establishing, and has established, major parts of the cancer program in what we call the Broad Street campus, which is where Temple Medical Center itself is located.

So the value of a cancer center to a large health system is the brand that was built over many years, as it was in this case?

RF: It’s amazing in many regards. First of all, it gives the old Fox Chase access to underserved populations, because Temple University Hospital is certainly one of the major safety-net hospitals in the Philadelphia market.

That is something we didn’t have, and the ability to affect the population is obviously going to be a big part of accountable care in the future. So we have that. And, in turn, we bring a new level of cancer research and care to what was Temple’s health system.

So members of the faculty of the bone marrow transplant unit—for example, the medical oncology group—have now moved and become members of the Fox Chase faculty, while they are still giving their care in their respective locations. So we’re moving throughout the system, integrating the surgeons, etc., and we will have common protocols and common quality controls, and really a much bigger cancer portfolio than Temple ever had.

And from Fox Chase’s perspective, we’ll be able to offer that to patients throughout the health system. We think it’s a win-win for both organizations.

When you accepted this job, did you have a prospective plan for turning the place around?

RF: I wish I could tell you that I knew everything ahead of time and had it all figured out, but it came relatively quickly, and we did some quick on-the-job learning.

We had a number of issues that we had to resolve. And I’ve been doing this for a while, so with the assistance of a great group of people here who were anxious to have strong leadership and move forward, we came up with a plan for what we were going to do. And that involves not only the fiscal health of the place, but also programmatic health.

But as far as the numbers, what did they look like when you came in, and what do they look like now?

RF: Well the numbers are a very big change, an important change, and sometimes we wish we could not worry about the money, but of course we can’t do that. It’s critically important.

The first year I was here, the Fox Chase family—the Fox Chase corporation recorded a $17 million loss, which is clearly unsustainable and not something we could live with. So we sat down with all of the programs and the administration, and we went line-by-line through the organization.

All of the clinical revenue from the organization at Fox Chase, all the margin, goes into supporting the research program. But it had become clear to me and to us as we went through the programs that, in many cases, we still had a probably an excessive amount of unfunded research being supported by the clinical revenue.

So we went line-by-line through that and looked at the programs, made very difficult decisions about what our core business was, what we could support, what was likely to be grant funded, etc., and we ended up taking $20 million out of the budget in a six-month period.

Now, I don’t believe that you can cut your way to prosperity, so we coupled that with an aggressive growth program. We were in the market, and marketing was reinstated. I started a program, which allows patients who call Fox Chase to be seen in the next business day. We call it our Rapid Access program. And it’s really had an amazing result.

And this year, all of our clinical programs—the major ones that are fiscally important: surgery, radiation oncology, and infusion—are all up double digits; 10-15 percent. And this year, instead of losing $17 million, we’re probably going to end the year on an absolute positive note of $8 million.

That’s a $25 million split!

RF: It’s a very significant turnaround for us. It enables us to do the things we need to do, make the investments we need to make, and continue to be a viable organization.

Obviously you can’t lose those kinds of dollars very long before you cannot function. And we’re very pleased that the organization is moving forward—and although these are obviously difficult decisions to make, and difficult plans to institute, I think most people think we have a stronger, better organization now.

The morale of the organization is much better, and we’re very optimistic and looking to a very bright future for Fox Chase as part of Temple Health.

What were the programs that needed to grow and what were the money drains that needed to go away? Is there a way to summarize that?

RF: Some of this was simply if people hadn’t had grants over a prolonged period of time—we can’t continue to support them; we just don’t have the resources in this day and age. Some of that was across the board.

But we did have some programs, which we probably weren’t focused on appropriately. Our genomics program was heavily involved in technology. We were not competitive in that regard, so we shifted the emphasis of that program to looking at genomics in special populations and in unique biology, as opposed to technology. So that’s kind of an example of a program that wasn’t performing in a way that was viable over the long term.

What we needed to grow was really—as I said, the place has a great history—but we needed to increase our translational science. That’s the new word of the day, and it’s really where the advancements and progress is going to be made. So we wanted to make our investments in that.

We acquired, when we went into Temple Health, some very fine scientists down at Temple who added some very important programs to us. So suddenly we had an ability to do an epigenetics program. [Jean-Pierre] Issa down at the Fels Institute [for Cancer Research and Molecular Biology] is now a full member of Fox Chase’s program and is now a program leader at our cancer center, and a very fine scientist.

We didn’t have a critical mass for that. So we’re looking at translational science; we’re looking at epigenetics. And Fox Chase has never been a traditionally dominant player in hematological malignancy—as you probably know, when I’m not running a cancer center, that’s what my world has been about for the last multiple decades—so we’re making a big investment in coming to prominence in hematological malignancy.

You have very strong competition. What would be the niche for Fox Chase in Philadelphia? I’m mostly thinking about the University of Pennsylvania and Thomas Jefferson. Where does Fox Chase fit in?

RF: This city is competitive. There are two comprehensive cancer centers, namely Penn and Fox Chase, and Jefferson is also a cancer center, but not a comprehensive one. We don’t shy away from the competition, my view is it makes us better—it keeps us sharper and performing well, so we welcome that.

Fox Chase Cancer Center: FY 2013 to 2015

There are also six million people in the metropolitan area of Philadelphia. There are a lot of people being seen in small community programs, which may or may not be the right thing, based on what they have. This market has not coalesced.

So what we think is, among other things, that we are a major player in what’s called the two rivers strategy, which refers to the wedge that comes up in North Philadelphia between the two rivers, the Delaware and the Schuylkill, and goes up into the other parts of Pennsylvania. That’s our location, and that’s where Temple is, and no one is serving the underserved population in the north Broad Street/North Philadelphia area. So there’s plenty of room, I think, for each of the three centers to be successful.

I think there’s room for each to develop their strengths and their programs. And our niche is going to be in the areas where I feel we can be strongest, and in the populations that we are serving that are unique for that regard.

Traditionally it was ovarian cancer, but what is it now? Is it still that or something else?

RF: Ovarian is still a big deal. We recruited Steve Rubin and Christina Chu from Penn, who joined us and now lead our gynecologic oncology program, which is largely ovarian cancer, of course. We recruited Henry Fung, who is the new head of our hematologic malignancy and transplant program. And that program is going gangbusters, and has increased its volume by about 30-40 percent already this year and is just doing very good things.

We’re doing epigenetic therapy, not a surprise since we have a new program in that led by Dr. Issa and our clinical colleagues here. And in addition we have two very solid important teams, one in GU malignancy, led by Robert Uzzo, who’s our chair of surgery, and is just world-class in that area. And the other in gastrointestinal disease, where one of our major new recruits is Wafik El-Deiry, who I can speak about in a moment, but is certainly coalescing our GI program and our colorectal program, and I think we’re going to see some quite amazing things come out of that.

This rapid appointment idea, is that novel? Is that done anywhere else? The guarantee that you will see a doctor right away…

RF: Every once in a while I have a good idea. And we jokingly call it I had a dream.

I walked into a town hall meeting with our faculty, and was thinking about it, and said, “Why do we have a lot of patients make an appointment and not show up after they’ve made that appointment?” We were having about 30 percent of patients in that regard. The cancer didn’t go away, so they must be going somewhere else.

So we said wouldn’t it be great—I know medically it might not make a difference—but how do you tell a cancer patient to sit tight for a week or so? It’s really important that they see somebody. What if we offered them next-day service?

The faculty stepped up and embraced that. That’s our Rapid Access program. Our number of no-shows on initial appointment is down to 3 percent instead of 30 percent. I think claiming it’s the only one would be a mistake, because we haven’t researched it, but there aren’t many programs that offer that service.

And they’re not seeing general oncologists. Over 90 percent of them are seeing subspecialty oncologists, who focus in the area of their particular disease. So we think it’s a wonderful satisfier for our patients. It’s increased our volume. And our doctors are working very hard to keep this happening.

It must be very difficult. The next day?

RF: The next day. It’s the next business day, to be perfectly accurate. We don’t provide that service on the weekends at this time, but next business day is pretty good.

It’s really an impressive thing, and our faculty has embraced it, and as I’ve said our clinical volumes are up 10-15 percent since doing that.

I’ve never heard of this being done anywhere else.

RF: Well, I haven’t either, but I don’t want to claim that it’s the only place. It’s not done many places, and it requires a real dedication to this and we’ve been able to do it.

When do you come up for your NCI grant review? Have you made any changes that would have an impact on the application?

RF: We’re writing at the moment. This is the terrible last year for the cancer center director of the core grant, where we’re totally immersed in that—we would be submitting in September of this year. So we’re heavily engaged in it.

It will be a different application than they saw before. Obviously, the leadership and the director have changed, the programs will have significant changes, and there will be new important people added.

So one works at this very hard; we think we have a good story to tell. We hope that the review committee and the NCI will be impressed by what we’ve done. We’ve worked very hard at it, and I think we’re a much better organization than we’ve been previously.

How’s the recruitment going? I’ve heard you talk about it as the ASCO party last year. You said that Fox Chase is going to be a fun place to work.

RF: When you’re losing money and people are leaving and people are discouraged and you can’t do what you need to do to keep things going, it’s not a good time.

And now, I think if you talked to our faculty, they’re enthusiastic; the place is stabilized. They like the programs and the ways the leadership is functioning. There’s just a whole new sense of optimism.

Like I’ve said, we’ve got some prominent and important people that have been added. And we’re continuing to recruit as we grow and build. We’re doing more targeted recruitment now for what we think will make a cohesive unit that can be competitive for certain kinds of grants. Wafik El-Deiry is probably my poster child at the moment. I hate to use that term, but you understand what I mean.

He’s an outstanding investigator. He was at Penn and Penn State. He was a Howard Hughes investigator. He’s an American Cancer Society full professor. He brought a million-dollar grant portfolio and about 16 people. He’s our deputy director of translational science. He’s hit the ground running and is meeting with all the disease-oriented groups, and he’s really catalyzing a new view of that. He’s turned out to be a great addition to our program, so we’re very excited.

Is there any other area that you’re emphasizing that you haven’t mentioned?

RF: There are things that we’re thinking about and developing, but I think we’ve covered most of those.

What are the long-range goals here? Where do you see Fox Chase five years from now? Ten years from now?

RF: I think these are very challenging times for health care. I don’t have to tell you that; everyone knows that. I think these are very challenging times for cancer centers.

I think we are challenged, as the accountable care organizations come in, as populations get to be restricted in their movement—it’s very important that we have a link to a health system in a baseline population. I think we’ve accomplished much of that.

On the other side of the coin, in order to do some of the high-intensity research and other things we’re on, we need probably resources that will not come in simply from the accountable care reimbursement. Therefore we’re going to have to be a destination center.

I think there will be probably enough people with secondary or independent insurance that will continue to go to the places with the programs that they want to be treated in. So we hope to have a baseline of people in a fixed organization, and then be very competitive for new state-of-the-art research and programs that will bring people from around the region and even the country to get the kind of therapies that we hope to offer in the near future.

Which areas do you think would make it even a national destination or even a worldwide destination?

RF: The programs were close to critical mass in the genitourinary malignancies—and I think you’re going to see some amazing things shortly in GI cancer that are going to be very exciting coming out of these labs, and led, but not only led, by Dr. El-Deiry. Those are probably our two prominent programs.

I’ve built major national programs before, in lymphomas and with Dr. Issa and myself and Dr. Fung, I think we will have a major program in hematological malignancy. Those programs need to be competitive in a national basis. And we need to develop them in that regard.