No more falling between the cracks

A cancer diagnosis is enough for patients and their families to deal without also having to cope with bureaucracy, queues, crowded outpatient wards, overburdened medical staff and parking problems when they need chemotherapy.

With the growing number of cancer cases (it is the number-one killer, as heart disease fell to second place several years ago) and oncology departments having only limited space, the idea of offering chemotherapy in the community at the health funds’ expense is logical.

As expected, many hospitals are not thrilled with the idea, as they fear competition from companies offering such care in the community – even though only two such two private chemotherapy clinics have opened in the past six or seven years.

The private firm behind the idea is A.P.C.

Health (the name taken from initials of the three founders), but it is known in Hebrew as Afek clinics (www.afek.org).

“We started by providing dialysis to kidney- failure patients 20 years ago,” says Prof.

Amos Pines, an internal medicine specialist who is A.P.C.’s medical director and one of its founders, in an interview with The Jerusalem Post. “The company’s main focus is still dialysis, but around seven years ago, we decided to provide chemotherapy to cancer patients in a community as an alternative to going to hospital oncology departments.”

Pines, who previously worked at Tel Aviv Sourasky Medical Center’s internal medicine department, says his company operates 10 dialysis clinics all over the country, including Jerusalem and Tel Aviv but also in the periphery. About 160 doctors, nurses, paramedics and others work for the company.

“We also give Botox injections for neurological problems – not for aesthetic treatments – when the patient has a medical indication covered by the health funds. In Ramat Gan, we also perform bone-density scans for diagnosing osteoporosis,” says Pines. “We don’t provide any service that isn’t in the basket of health services. Even though we are a private company, the cancer patient pays nothing for our treatment, as the cost is completely covered by the health insurer.”

A.P.C. Health runs an oncology clinic in Ramat Gan and Ashdod; the latter city has no general hospital, even though one is now being built. Ashdod residents who need chemotherapy thus would have to travel some distance to get it if there were no private clinic. While A.P.C. has competition from a private company that provides dialysis for kidney-failure patients, it remains the only one so far to have freestanding clinics providing chemotherapy treatment in a community setting.

Oncology patients always have the possibility of getting treatment in a hospital oncology department, “But given the choice and informed about A.P.C. clinics by their health funds... many prefer to go to a community clinic,” says the A.P.C. Health medical director.

“We didn’t just open dialysis and oncology clinics in this or that community,” he continues. “It was the health funds who had a lacuna and asked us to provide services in the community. We open clinics where the health funds find a need,” he explains. For example, health funds asked the company if it was willing to open another chemotherapy clinic in Kiryat Gat, which does not have a hospital.

“Patients are likely to think – and I understand them – that cancer is a serious disease that needs to be treated in hospitals. They [once] felt the same about dialysis. Today, two decades after we started, 60 percent of dialysis patients still go to centers in hospitals three times weekly to have the wastes filtered from their blood, while the rest go to clinics in the community. “But it’s a matter of education for cancer patients to understand that some treatments can be performed by highly trained medical professionals in the community,” says Pines.

Asked whether the Health Ministry has a pro-hospital or pro-community clinic orientation, Pines says that the ministry does not discriminate.

“They don’t make any problems for us.

What can be performed at the community level is clearly stated. A private clinic has to meet the ministry’s standards in the level and number of medical personnel and the available equipment. If we meet the criteria, we get approval.”

Pines notes that in the US and many other Western countries, “chemotherapy is provided in most cases in community clinics rather than in hospitals. Our services are actually cheaper than the official hospital rates, but the various health funds make bulk agreements with hospitals that lower the price.”

The A.P.C. Health’s oncology clinic in Ramat Gan treats patients mostly in the Meuhedet and Leumit health funds, while in Ashdod, they work also with Maccabi Health Services. As Clalit Health Services owns its own chain of hospitals, they have little incentive to enter into agreements with A.P.C. Health.

ONCOLOGY PATIENTS treated at the clinics list the benefits they enjoy from not having to show up for care at a general hospital oncology department. For many patients and their family members, just finding a paid parking place in the hospital’s lot is a major challenge. The private clinic has its own roomy and free parking lot. It also offers not only infusions but also consultations with dieticians and social workers, and some complementary care, such as reflexology, to relax patients.

The clinics offer a much more pleasant environment, they say. The hospital is massive, with thousands of people there ever day. One has to be careful not to catch a viral or other infection. In the community clinic, one is not exposed to nosocomial diseases spread in hospitals themselves, and there is privacy, with each patient in an enclosed cubicle.

One of the most valued benefits is that the clinics open at 4 p.m. and remain open until 7 or 8 p.m., several days a week, with shorter hours on Friday. Thus neither patients nor their accompanying persons have to miss work to come for the treatment. Most hospital oncology outpatient facilities close before 4 p.m.

Pines says that except for the chief physician, his oncologists work in public hospitals through the mid-afternoon and then come to A.P.C.. Pines says that despite the general shortage of nurses and doctors in the country, he does not have any problem finding suitable medical personnel. They appreciate not having to work shifts late at night and on holidays and weekends. The A.P.C. doctors are the same senior physicians who work in hospitals, not inexperienced doctors who work only in the private clinics, he explains, while most of the nurses work only for the company and do not “moonlight.”

Eliminating the red tape for cancer patients is probably the biggest boon. Families that have gone through chemotherapy are familiar with the procedures in the hospitals; undergoing tests and waiting for an oncologist to look at the results, choose the chemo drug to be used, locate an empty bed and find a nurse to give the infusion and then again to disconnect the tube at the end of treatment.

But Pines states that this does not occur at his two clinics. “The patients are sent to their health fund clinic the previous day to undergo blood tests. We automatically receive the results, order the drugs and prepare the chemo. Our patients are given an appointment at an exact time. They know that they will be finished and sent home a few hours later.”

“ONE CAN’T compare the attitude and the warm, personal relations I have with the A.P.C. staff to the hospital,” says a health fund physician who was herself diagnosed a few months ago with breast cancer. “At first I was treated at a hospital, and from being a doctor, I suddenly became a patient. We doctors don’t know how it feels to be sick. I was so discouraged and fed up that I even contemplated stopping my chemotherapy treatments altogether.

“Then my health fund told me about the A.P.C. clinic in Ramat Gan. I had never been there or even heard about it. It isn’t even in my city. But when I got there I found it was completely different than the hospital oncology department’s outpatient services. Here, you almost don’t feel that you’re a patient.

Unlike a hospital, where you see patients who are very weak and debilitated, I see more pleasant things that don’t don’t remind me where I could be a year from now. I don’t have to look for a bed or wait in long queues.

“Having cancer is enough to struggle with; I don’t need more challenges. I’ve been treated here for four months, and the staff all smile at me and give me the feeling that they really care about my health instead of being on an assembly line or feeling I am an imposition. They give me the feeling I can overcome the disease,” she told the Post.

“Now, I recommend it to my own health fund clinic patients.”

Eti, a woman whose 79-year-old father is being treated for cancer at the A.P.C.. clinic in Ramat Gan, lives in Ra’anana and brings him from Netanya to the clinic for chemo every three weeks.

“The care is so good, not only medical but the personal relationship. I can easily park the car. As we come in the afternoon, I don’t miss work. My father is not exposed to infectious diseases, and he is not exposed to unpleasant sights. He enjoys having his privacy,” she relates.

Another breast cancer patient, Eti P. of Netanya, also had been treated in the oncology department of a hospital in the center of the country but felt she had fallen between the cracks.

“I was so lost, having to wait in long lines, picking up infections. My health fund, Kupat Holim Leumit, said it would be possible for me to undergo chemotherapy at A.P.C. in Ramat Gan.

I feel as if I were home. I’m constantly hugged. There’s a different atmosphere.

If I don’t come one week, the secretary and the social worker and other staffers call me at home to see if I’m all right,” Eti said.

ASKED TO comment on community chemotherapy services, almost all the hospitals contacted refused to give their opinion, at least on the record.

Prof. Tamar Peretz, head of the Sharett Institute of Oncology at Hadassah University Medical Center in Jerusalem’s Ein Kerem, was an exception, and made a short and largely positive comment.

“In principle, I support the idea of oncology services in the community as long as they are provided properly. We at Hadassah have an oncology service in the community so that patients do not have to visit the hospital.

We also have ambulatory services on the Ein Kerem and Mount Scopus campuses with over 20,000 visits a year.”

But Prof. Alberto Gabizon, chief of oncology at Jerusalem’s Shaare Zedek Medical Center, has a more conservative view.

“Israel is a small country with much shorter geographical distances to reach a hospital.

In Ashdod, there is no hospital, so maybe cancer patients there should be able to go for chemo to a community clinic. But I am opposed to a comprehensive switch to community care. In most cases, this is unnecessary.

Hospitals have all the experts on-site, the most experience and all the possible infrastructure and equipment. Chemotherapy is possibly toxic to the patient, and sometimes there are acute reactions. So only the hospital can cope with all eventualities,” says the senior Jerusalem oncologist.

“A patient’s condition can suddenly change, and a different dosage has to be given. The standard protocol may have to be changed. Chemotherapy is a complex, dynamic treatment, so I don’t think a private community clinic could cope with all cases,” says Gabizon. “Quality of care is most important.”

But he conceded that hospitals should do all they can to make ambulatory chemo treatment less of a hassle by providing more pleasant surroundings and alleviating the parking problem for cancer patients.

“The hospital oncology departments need not regard us as a threat,” concludes Pines.

“While we want to share the business, we will not take a big chunk of patients away from them. It’s a very gradual process. We are small, with only about 15 patients per shift in Ramat Gan. Hospitals may have have hundreds of patients a day. But our patients feel the difference."