When Francoise Watts talks about her disease, she does not call it “cancer.” She doesn’t even refer to her current condition as “remission.” Instead, she says simply that she is doing well.
“When I was diagnosed it was a very hard time. When you hear that word it puts you in your mortality,” Watts said. “I’m trying to live well. I never wanted to be stigmatized as a ‘survivor,’ I just want to live as fully as possible. But everyone is different.”
Originally from France, Watts moved to Lynchburg in 1987 and taught French at Randolph College. When she was diagnosed with breast cancer in 2016, she became a patient at the Lynchburg Hematology Oncology Clinic, the independent physician group that, until recently, provided cancer care services at Centra Health.
From her diagnosis all the way through the surveillance period, when doctors checked regularly for a resurgence, her treatment spanned eight years. She just recently had her final checkup with the same medical oncologist who had supported her throughout the whole ordeal.
In February, it was announced that the decade-long contract between the clinic and Centra would be ending, and patients at the cancer center would no longer have access to their physicians.
“Those people who are in the middle of their treatment and they don’t know who their doctor is going to be, that’s going to be very destabilizing,” Watts said, adding that receiving a diagnosis and going through treatment is very difficult both physically and mentally.
Some providers worry that the turnover in hematology and oncology in Lynchburg and the inevitable reliance on traveling health care workers could negatively impact access to health care in the Lynchburg area, and that patient care could become more fragmented.
Changes at Centra
In February, letters from Lynchburg-based Centra arrived in patient mailboxes, announcing that its contract with the clinic would end, and that the doctors who had managed their care for years would no longer be providing services at Centra.
The end of the contract between the two entities comes months after Centra filed a lawsuit against LHOC, alleging that the physician group overbilled for patient services from 2016 to 2021.
According to the court documents, Centra sent a letter to LHOC demanding repayment that totaled about $7 million for the five-year period. LHOC refused to pay, the suit alleges. Centra filed the lawsuit in December.
The clinic had not filed a response to the lawsuit as of April 4, and no lawyer for LHOC was listed in court documents. Multiple LHOC physicians were contacted for comment for this story, but none responded to inquiries.
Stephanie McBride, communications director for Centra Health, said that the lawsuit is unrelated to the failed contract negotiations between the two entities.
“Centra takes all compliance and regulatory matters very seriously but hopes to resolve the matter with LHOC as soon as possible. Despite this compliance matter, Centra had hoped to continue its professional relationship with LHOC, offering the group a new agreement or, alternatively, an extension of the current agreement, but LHOC refused both,” McBride said in an email.
About 10,000 patients received hematology and oncology care at Centra Health in the last year, accounting for approximately 18,000 visits. The whole health system serves about 500,000 people in Southwest and Southside Virginia.
The physicians with LHOC managed the treatment plans for patients with cancer and blood disorders until March 29. On April 1, a new group of providers employed directly by Centra Health took over the caseload.
Watts had her very last checkup with her doctor just weeks before receiving the letter that announced the changes at the cancer center. Even so, she felt unsettled.
“[The letter] was very confusing, and it was signed by someone I didn’t know,” Watts said. “The letterhead was from Centra, but the person signing it was from oncology services. It didn’t make any sense to me.”
The rise of professional services agreements
Relationships between physician groups and hospitals are a complicated part of the health system bureaucracy that many patients are unaware of until contractual agreements between the two entities change or, as in this case, end completely.
In September 2014, Centra Health entered into a professional services agreement, or PSA, with LHOC, which had previously been a private practice. While Centra essentially bought the practice, PSAs allow physicians to maintain autonomy since they’re contracting out the services they provide.
PSAs have grown in popularity over the last decade because they carve out space for doctors between the traditionally sought-after private practice, which comes with high administrative costs, and direct employment with a health system, where they have less negotiating power.
The building that houses the cancer center is owned by Centra, and Centra managed compensation for the LHOC providers. The physicians even wore Centra Health name tags, appearing to patients as employees of the health system.
The number of providers in the group fluctuated over the years, with about 14 providers in the early days of its contract with Centra. The number of physicians decreased in the months leading up to the end of the contract, with many leaving for retirement or prospects in other communities. At the time the contract expired, McBride said only about five providers were still a part of the LHOC practice.
McBride said that the doctors with LHOC oversaw patient treatment plans. Other services, such as chemotherapy and surgery, and other health care workers such as nurses, will remain in place.
In the letter signed by Thomas Angelo, vice president of oncology services for Centra, the onboarding of a new team of providers was announced. These providers would take over care for patients with cancer or blood disorders.
“Your medical records, treatment plans and ongoing care will be transferred to a new provider with Centra Medical Group Hematology and Oncology Clinic,” the letter read.
Continuity in a ‘destabilizing’ situation
The treatment and surveillance of Watts’ disease spanned eight years under the same medical oncologist, who now is employed with Virginia Oncology Associates in Suffolk.
“It was very reassuring to have the same doctor. You build a relationship of trust when things are so destabilizing. You want someone who has followed your case from the very beginning. You lean on that relationship. It’s important that you’re supported,” Watts said.
When it comes to cancer care, treatment is expressed in terms of years and involves an array of specialists. A consistent team of providers not only serves as an emotional life preserver to patients but can also support continuity of care.
It was a comfort to Watts that she did not have to explain her situation to her doctors at every visit. When she had a problem with her treatment, her team at the cancer center addressed the issue quickly, and she never had to worry that another problem would arise.
Centra Health’s initial staffing plans for the new hematology oncology team consist of 10 physicians and 12 advanced practice providers, such as physician assistants and nurse practitioners, McBride said.
Of the 22 new providers, 19 are traveling health care workers on six- to 12-month contracts. These providers are employed by a separate company, but Centra is responsible for their compensation and pays them a stipend to cover living expenses.
Throughout the COVID-19 pandemic, the U.S. saw a sharp increase in demand for traveling providers, which cost much more than hiring a permanent employee. Many hospitals across the U.S. experienced a significant financial downturn due to increased dependence on traveling health care workers, according to data from the American Hospital Association.
Centra will fund these positions out of the hospital’s operations budget, McBride said. The hospital leadership is attempting to recruit these providers to become permanent employees, she added.
Not enough doctors
Physician shortages have been anticipated across many specialties for the last decade. But as the COVID-19 pandemic accelerated retirements, career changes and resignations among health care workers, the shortages hit faster than expected.
Oncology is no different, said Dr. Richard Ingram, a medical oncologist in Winchester who’s president of the Virginia Association of Hematology and Oncology and a co-founder of the Appalachian Community Cancer Alliance.
Even urban centers are struggling to recruit specialists to their cancer centers, and the recruitment and retention challenges are only amplified in rural areas, Ingram said.
From diagnosing to creating a treatment plan to radiology and chemotherapy, treating cancer requires a lot of different specialities. The process is often difficult to navigate even at urban centers. For patients who are rural, their care tends to be very fragmented, Ingram said.
The addition of traveling physicians, also known as locum tenens, often adds to this.
“Loc*ms can provide emergency coverage, but it’s hard to have true care and surveillance, which can take place over five years or more,” Ingram said.
For Lynchburg patients who have the time and the means to travel to see a medical oncologist for more consistency in their treatment, there are cancer centers in Charlottesville at the University of Virginia Cancer Center and in Roanoke at Carilion Roanoke Memorial Hospital. Both are about an hour’s drive from Lynchburg.
While physicians at these centers will always take on patients when need be, most are juggling high patient loads, Ingram said.
“None of the cancer centers in Virginia are underfilled,” he said.
The team at UVa has seen an increase in referrals from the Lynchburg area, according to Eric Swensen, public information officer at UVa Health.
“We are closely monitoring the situation and proactively coordinating with our teams to ensure we can efficiently accommodate and provide care for hematology/oncology patients from the Lynchburg area. We are examining our current capacity, particularly in infusion services, and are prepared to extend our hours if necessary to meet the increased demand,” Swensen said in a March email.
Last year, the center saw 32,000 hematology and oncology patients. On average about 1,000 patients from the Lynchburg area sought some form of care at UVa Health every year.
“Not all of these patients stay at UVa Health for care, but may see us for additional workups or second opinions,” Swensen said.
The medical director of the cancer center at Roanoke Memorial Hospital, Dr. William Fintel, did not report an uptick of referrals from the Lynchburg area, saying only that his department is “here and ready to serve pediatric and adult hematology and oncology patients.”
