Community Oncology at a Crossroads: Navigating Policy, Progress, and Practice

In this episode of Treating Together, host Pallav Mehta, MD, medical oncologist at MD Anderson Cancer Center at Cooper, assistant professor of medicine at Cooper Medical School, and medical director of Reimagine Care, is joined by Debra Patt, MD, PhD, MBA, oncologist and executive vice president at Texas Oncology. Patt also serves as the president of the Community Oncology Alliance (COA). Their discussion focuses on the rapid transformation of community oncology and the growing pressures shaping its future.

Themes and Key Discussion Points

The episode focuses on the central role of community oncology in preserving local, quality care. Highlights include:

• The Evolution of Community Oncology: Drs Mehta and Patt explore how community oncology has changed over the past 2 decades from largely independent practices to consolidated health systems and clinically integrated networks. Financial forces, including the 340B program and broader reimbursement reform, have significantly influenced consolidation trends.
• Policy as a Driving Force: Dr Patt explores how legislation such as the Inflation Reduction Act (IRA) and evolving Centers for Medicare & Medicaid Services (CMS) reimbursement models may impact drug payment, cash flow, and practice viability.
• The Explosion of Targeted and Advanced Therapies: Oncology has entered an era of unprecedented therapeutic expansion. With this progress comes more complexity: longer treatment durations, higher toxicity management demands, and logistical hurdles of administration.
• Digital Transformation and AI Integration: With the accelerating role of digital tools and artificial intelligence (AI) in practice, practices face both opportunity and implementation challenges.
• Workforce and Rural Access Challenges: The conversation addresses mounting physician and nursing shortages, burnout, and the sustainability of rural cancer care, requiring a reimagining of policy, workflow efficiency, and staffing models.

Transcript

Mehta: Welcome to Targeted Oncology's Treating Together podcast. I’m Dr Pallav Mehta; I'm the medical director of Reimagine Care and a practicing medical oncologist. And I have with me today Dr Debra Patt, and I will let Dr Patt introduce herself.

Patt: Thanks, Pallav. It's a pleasure to be here. I'm Dr Debra Patt; I serve as an executive vice president of Texas Oncology, where I've been a breast cancer specialist for years. I serve as the president of [COA], which is an organization that really supports community oncology practices, which have changed quite a bit over time, and I serve on the board of ASCO. My practice is a little bit different because I am a doctor 20% of the time. The rest of my time I spend in clinical informatics, public policy, and business strategy.

Mehta: Great. There's so much I know we could talk about, but I guess the focus of this conversation, we wanted to get your general take on this relationship between community oncology [and] the academic medical centers. When I started in practice, I was in a community practice for about 8, 9 years, which I still absolutely like, [it] was a great time. I think the evolution of community practice looks different today than it did 20 years ago. To start… where do you see community oncology today? And maybe go back to your own story when you started out in practice and what the world was like, because it seems ancient.

Patt: It's changed quite a bit, yeah. I will say, community oncology today looks really different than it did 20 years ago. I think the ways in which it's changed have been necessary in terms of business strategy, because we can't deliver on the mission of delivering great cancer care to the patients we serve in our communities without sustainable business solutions, because we have to stay afloat. And so that's caused a lot of consolidation, both in the hospital systems and to clinically integrated networks that help to provide us a lot of infrastructure. I think that the benefits of that have been tremendous to what we can offer in practices. For example, I have 70 clinical trials in my office here in West Austin, and in Texas Oncology's 300 sites of service, we have clinical trials, not in every single clinic, but in each major region. We have access to the same number of clinical trials. And really, that was something that I think that infrastructure investment made it quite difficult to operationalize 20 years ago. So I think in community practice today, because of how we think about evolving, has really changed what we're able to offer to really be the most modern cancer therapy that we can give, which is great.

If I can start with a little bit of a history lesson, I'll say that historically, most patients were treated in communities, but there were initially some financial drivers that really fostered hospital consolidation. If you look back to 1992 with the Public Health Services Act, there was a portion, 340B, that allowed tax-exempt hospitals that see a certain percentage of patients that are financially vulnerable to purchase drugs at a discount. At that time, those drugs cost a lot less, and the magnitude of that change was quite different. But what happened was, because of this financial incentive, it became financially advantageous for those tax-exempt facilities to go into the cancer business and allow that to be sustainable and profitable for them. And so we observed a lot of consolidation of community oncology practices to the hospital system.

I will say there was a real pivot again in 2010 coinciding with [the Patient Protection and Affordable Care Act] because there was a change to allow contract pharmacy relationships with those tax-exempt hospitals that were innumerable. So before, while they had to have their own pharmacy, it was argued in 2010 that this is really discrimination against some rural hospitals. They should have innumerable contract pharmacy relationships. And the natural consequence then is if you're a hospital, then you have innumerable contract pharmacy relationships that allows you to grow the financial impact of that program. And sometimes it's for patients that are truly seen in the hospital. But that program is now applied even to some patients that, like in Austin, Texas, where every hospital that surrounds me is a tax-exempt facility with 340B. Some of my patients that I care for end up having their oral oncolytic that I write for—like if I write for palbociclib [Ibrance] and letrozole [Femara] in practice that's filled by their pharmacy benefit manager [PBM]-aligned pharmacy—it can be associated with a 340B benefit for my adjacent hospital because they're aligned with that pharmacy, because after 2010 they developed these innumerable pharmacy benefits.

And so the natural consequence is that we've had tremendous growth in that program, because it's now over 100 billion dollars of purchasing of drugs in the country. It's like…the biggest drug discount program that the government doesn't actually fund. And I will just say there are some natural consequences of that. I think while the intent of the legislation was to provide a mechanism to care for vulnerable patients in every population, I think what's happened is there is a tremendous arbitrage opportunity for systems to grow this program that can be profitable for them in different ways. And then, because that burden is borne on the backs of manufacturers…if you're a manufacturer and out of the box that you're selling 40% of your drugs at a 50% discount, then the natural consequence is you're going to raise drug prices to maintain a stable profit margin. So like all well-intended policies, there are some natural consequences that happen that have their own market force changes that we may not anticipate.

That's a long explanation for what's happened in community oncology: [a large number of] practices have gone to the hospital systems because of that. The other thing that's happened is a lot of community oncology practices, if you'll envision to 30 years ago…have joined clinically integrated networks like US Oncology, [American Oncology Network], OneOncology because it offers them the ability to grow their offerings much more with sustainable models. Our number of clinical trial offerings, that operational infrastructure is tremendous. I wouldn't be able to really do that if I was by myself and had a shingle, even the compliance of attending all the research requirements would be just too cumbersome. The other place where it offers us benefits is things in like group purchasing, because the buying of the drugs is now a[n] important part of the sustainable business model, and it allows us to think about the management of the practice and some of the offerings that we give a lot differently. And so I think that the change that we've observed in community oncology has been a natural consequence of some of these market forces and as we look to the future I know that you and I very much want to see happen with advanced therapies, I think we'll continue to change in how we think about delivering what patients need in our communities.

Mehta: Wow. I knew a little about the 340B connections, but I didn't realize the way [in which] the prescription gets written in the community and the potential relationships. I guess I'm not surprised.

Patt: It's complicated, but to put it simply, if I have a [hypothetical] patient, Jane Smith, and she had a mastectomy in the hospital 3 years ago for her breast cancer, but now I treat her for metastatic breast cancer, and I write for her to start letrozole and [palbociclib]. And that script is steered to a [PBM] aligned with her insurance company and their retail pharmacy, which happens 50% of the time. The pharmacy will say, and the pharmacy has an interest in saying, Jane Smith, when we adjudicate this script, I can identify that Jane Smith is a hospital patient because Jane Smith has a hospital medical record number from when she had her mastectomy. And Debra Patt, her doctor, has privileges at that hospital, like any good community oncologist have privileges at all the hospitals near me, and then they can purchase the [palbociclib] from Pfizer for 50% of the cost. They can charge Jane Smith's insurance, the full price of the drug, and the remaining 50%—arbitrage, if you will—can be split between the pharmacy, the PBM, and the hospital system through these structured…margin-based contracts. So, as I think people are aware now about the ways in which PBMs, which were designed to save money, have sometimes changed the nature of how drugs are paid for and altered some of the market dynamics. And it's not really transparent, right? It's tricky to figure out.

Mehta: Yeah. And given the volume of new drugs, I talk a lot about—when I do the fellow and the resident talk—2001 when I graduated medical school, it was a month before I graduated, [imatinib; Gleevec] gets approved and I think that was our penicillin moment. I think [trastuzumab; Herceptin] was a year before, maybe [rituximab; Rituxan] a year before that. But [imatinib] gets approved and all of a sudden, there's this shift in how we think of the success of targeted medicines. And even to this day, [imatinib] is still one of our most successful targeted orals. But since that time, and I've counted recently, I think there's 170 oral agents that have been approved. And just… the cost impact—how does a fellow keep up today? How does an oncologist keep up today? And each drug just happens to cost… at least the published cost of about $20,000 a month.

Patt: And in myeloma, there are a lot of expensive drugs that we're putting together. So it becomes more complicated. You and I are on the same cadence because I can remember exactly where I was in the room of my basic sciences in Baylor College of Medicine when the New England Journal [of Medicine] article came out for [imatinib]…and changed the course of how we think about cancer therapeutics. And I like to use analogies or metaphors a lot to describe things. And as I describe this to noncancer specialists, I often say that if you think about cancer as the barrier, the door that's blocking people's journey of life, we've always had great tools to take down that door, but they've just been blunt instruments like axes. Because surgery and radiation and chemotherapy, they do what they're supposed to do, but there's a clear and direct impact on the patient, and they're really useful. But as we think about targeted therapy, oftentimes it's a lot more elegant because it's like realizing that that door has a lock and that we can find a key to open it to allow patients to continue on that journey of their life and be unimpaired by their cancer. I would say that I think that it's changed that our goals, no longer as cancer specialists, are to let people merely have improved survival, but really to let them live well with chronic disease control.

Mehta: Yeah, and you're right. It's certainly a lot more success. I think we saw the [American Cancer Society] stats for the first time, 5-year survival in all cancer at 70%. And then some cancers, even myeloma. Actually, you mentioned a great example because we know all that progress in myeloma is not from surgery radiation. It's from these amazing targeted [agents].

Patt: And because you trained when I trained, you know that the average survival for someone diagnosed with the myeloma was 3 years. My, how that has changed. And, what a privilege for us to practice in this time that there's tremendous progress. It's an amazing time in cancer medicine.

Mehta: Yeah. I'm curious then, with even just the way you're thinking about the community and the way I've thought about community practice, there was a time where we thought about it as these individual entities.

Patt: Doesn’t look like that anymore.

Mehta: Yeah, it really doesn't. And I'm curious then, when we think about this relationship between the community and academia, that relationship is very different today because of some of the things that you're saying with these integrated networks, but how do the pressures change then for that community? Because back then, especially around 2010, it was that Medicare modernization or one of the acts came out around then.

Patt: Yeah.

Mehta: I remember changing our quarterly meetings at my practice and all of a sudden, every quarter was a scary time. But today, what are those pressures? How would you think of a community practice today? What are they worried about vs 10, 20 years ago, what they were worried about?

Patt: I would say different kinds of challenges. I think that drug policy is always something that concerns practices because you can't do what you're doing and live the mission if you don't have sustainable business solutions. So that's really important. We look at things like GLOBE and GUARD, which are new initiatives, and the IRA; how [they] will influence drug payment will have a great impact on cancer practices. So we have to sort that out.

I think that public policy remains the greatest potential threat to cancer practices. Because of that issue, because we have to keep the lights on. And so, how those things impact us matter. So right now, in the [IRA], it's not clear how the effectuation process works, how the discount is really going to be delivered, and if there will be potentially a 6-month delay in payment. Potentially it could make some practices underwater. There's legislation in flight, nothing that's passed yet. But Senator [John] Barrasso had championed before the [IRA] passed to try to hold physicians harmless in that; GLOBE and GUARD are manufacturer and government transactions. And so it holds physicians harmless. So we'd love to see that in the IRA too. Public policy remains the biggest threat. But I think there's other things that we have to navigate. If I look to our future, the 2 that keep me up quite a bit, that I end up spending hours on every day as a leader in my practice is how we manage digital transformation, and also how we provide the appropriate infrastructure to really deliver advanced therapies in a meaningful way.

Taking the first part of that, the digital transformation piece, it's an amazing time. Not only with technical solutions, but also in how AI can augment all the things that we do. I don't know a doctor that doesn't have OpenEvidence up at their fingertips at some point. And I read a statistic the other day that 40% of patients are querying ChatGPT before they before they see the doctor. I've seen many models of clinical decision support, and we all observe where good technical integration works well, and then we have heightened expectations of everything else we would all like for our healthcare interactions and appointment scheduling to work—a lot like how I order my toilet paper on Amazon, because that's just easier. We know that technically it's possible, but we're limited because healthcare has always been late to adopt a lot of that digital transformation for a lot of important reasons. There's a lot of privacy laws [like] HIPAA that stall progress in healthcare because the liability for a practice or any healthcare entity is pretty substantial if there are breaches there. And so that's one issue. And then there are big investments, but there's a lot of change that we have to make. I'm concerned not just for community oncology, but for all of healthcare that we need help in getting there to make that digital transformation. [I’m] speaking candidly just about Texas Oncology because I'm our physician leader for our transformation office, and we're a big practice. We're the biggest practice in the country with 300 sites of service. we have 122 projects to implement in the next 3 years.

Mehta: Wow.

Patt: Just think about what that list looks like, because how we communicate with patients, how we fill medicines, reschedule appointments, make sure that patients’ symptoms are managed as quickly as possible, optimize our [group purchasing organization] contracting… There's a lot of flight going on and…because I've been working in the clinical informatics space and doing clinical decision support for a long time, I thought [that] 10 years ago the big challenge was going to be deciding which vendors to work with… And it's clear to me… that that's the easiest choice, not that it's trivial because it's really important, but the hard part is implementation and change management in our organizations, because what we do is so complex already and healthcare is going to need help to do that well. I think that's one real challenge we have for our future.

Another real challenge…is advanced therapies. I’m sure you read the news out of the American Society of Hematology meeting in December—great year for Kite Pharmaceuticals, their [anitocabtagene autoleucel] has fantastic data in multiple myeloma. [Chimeric antigen receptor T; CAR T] therapy and other advanced therapies are going to be an important part of our future. But today, it's like a Ferrari that doesn't have a highway to drive on. Because today, less than 20% of patients that would be eligible for those therapies will have access to those therapies, for a lot of important reasons that have to do with the clinical infrastructure, the reimbursement—right now, the biggest hazard is this reimbursement bucket. I think there's a huge gap in patient education. And then, operationally, the coverage; even if we figured out how to make sure that the hospital is aware that we're doing this [treatment], how to make sure to have prophylactic tocilizumab [Actemra] and [intravenous immunoglobulin] paid for, the reimbursement piece around CAR T is really complicated. Also, the clinical infrastructure to support these patients after hours is complicated.

I think practices and organizations are going to go one of 2 ways: they're going to buy or build. In Texas Oncology, we're building, because for over 10 years [we] have had a bunch of nurses that work virtually. Today, that's 100 nurses that work virtually. We've implemented electronic patient-reported outcomes and over 100,000 patients on active therapy when they push in symptom needs… We follow a lot of key performance indicators, so we have operationalized that. But most practices don't have that. And they're going to need partners—even if you look at City of Hope, they need partners. I know you know Reimagine Care very well. I think Reimagine Care fills a great niche here, because most practices aren't going to have the ability to stand up the infrastructure to respond to patients’ symptoms for advanced therapies like CAR T in a timely fashion that's necessary to make those safe and effective. They're going to need clinical infrastructure to buy, to have relationships with organizations like Reimagine Care, to offer this nursing support after hours, to support these patients, to try to build the infrastructure of this highway so we can take that Ferrari out for a drive.

Mehta: Yeah. That's certainly an apt analogy for these therapies where it's something I've been thinking about a lot these last 6 months. As a breast oncologist, it's not something we're using yet, although I do know there's some HER2 bispecifics not too far down the road. Everything’s a culture shift and culture shifts in medicine—particularly in oncology, we're a little more of a conservative bunch—adopting these new things and being comfortable delivering these… is this next wave of challenges.

Patt: And how amazing is it to be an oncologist in this moment in time? We have so many new and novel therapies at our fingertips. The pace of change is really fast. It's an exciting time, but it's also a time that's quite labor-intensive with different needs. I think that using multiple therapeutic modalities in a given time interval, whether it's just combining endocrine blockade with CDK4/6 inhibition like we do in advanced ER-positive breast cancer or I'm sure you've been following these maintenance strategies, like the PATINA [NCT02947685] strategy and HER2-positive breast cancer, or adding tucatinib [Tukysa] in HER2-positive metastatic breast cancer to add to the maintenance therapy that improves progression-free survival, you now are getting either an infused or an injected drug and [pertuzumab; Perjeta] and [trastuzumab], and then also an oral targeted therapy. And it becomes increasingly complex for the doctor to manage toxicity, for the patient to anticipate potential [adverse] effects. And I think we know from our 20 years of experience fraught with bruises and injury, that when we don't do that well, the patient suffers because they experience toxicities, they're not managed in anticipated early, then they end up discontinuing their therapy prematurely and they don't benefit from that strategy. As we have more therapeutic interventions, some of them have some dangerous toxicities that we need to be very proactive about educating patients and managing well, and today I think that's a gap in what we do.

Mehta: Yeah, it's the days of a patient getting their surgery and then being done. Whether it's lung cancer, colon cancer, breast cancer, I can't imagine a scenario, even in ER-positive breast cancer now, so many more folks are on adjuvant CDKs. It's almost like it's not just the volume of patients. When I think of complexity, there's obviously more patients, but there's more treatments per patient, and then there's more duration per treatment per patient.

Patt: Exactly right.

Mehta: And the more metastatic patients who are thankfully living much longer.

Patt: It's a great problem to have. But the management burden has increased substantially. And I think the management burden is also exacerbated by the fact that people are ordering their toilet paper on Amazon and they have an expectation that all things should work like that, which, candidly, they should.

Also, we're in the setting of a healthcare shortage: that there is a nursing shortage nationally, radiation therapist shortage, dosimetrist shortage, physicist shortage. There are healthcare shortages that aren't going to be different for a decade, and so, fail to change at your peril because it won't be sustainable. The 2 threats and how oncology and healthcare needs to change are urgent because we have these other pressures on the ecosystem in the staffing shortage that we need to be more efficient.

Mehta: Yeah. I'm curious with your roles at COA, your experience in public policy and in the community—how is COA looking at these pressures in community oncology?... Th[is] relationship between community and academia is a different relationship now, but what is COA doing now for…say an independent practice [that has] 5 docs with their nursing team, a small business vs an integrated network[?]

Patt: Yeah, it's a great question. COA does a lot, and I think COA has always done a great job of trying to meet the needs of independent community practice. I'm the president this year, which is great. This year's meeting will be predominantly focused on innovation... I have a meeting today with Jeff Hunnicutt, who's the CEO of Highlands Oncology, and Lucio Gordan, who's the president of Florida Cancer Specialists, and we are curating an innovation hub at the meeting this year, which is April 2026. So please save the date on your calendar.

Mehta: Yeah, I'd love to go. The last one I went to was [in] 2008, so I'm sure this is very different.

Patt: We're having an innovation hub because I spend several hours a day working on AI stuff, meeting with vendors, trying to understand how we optimize digital transformation. But I look at my colleagues and there's no way that everyone has time to do that. I think we need to show them solutions that are working so they understand how they integrate and how they're working. They need some easy buttons as they try to embark upon digital transformation. I think practices are at very different places as they think about how to evolve. But that's one thing that COA is doing, is that we're going to have an innovation hub at the meeting. We've stood up a transformation task force to try to think about how we optimally support practices. That's really important again, because this is going to be a pain point. We all will struggle with how to do this. I will say I feel like we're pretty far along in how we do this. Not all of our doctors, but most of our doctors use ambient AI to record their visits to try to diminish the burden of dictation. We have a lot of AI and other digital tools that have been in use for many years. We've had clinical decision support for like 10 years now, so lots of ways that we use it well. But we struggle with it, and I feel like we have a lot of people and resources dedicated to that. So that's one thing in the task force.

Another thing is there is this focus on advanced therapies… COA has a resource there and we will have some sessions at the meeting to educate folks. There is a task force for advanced therapies within COA also to manage that. COA has also done a lot in value-based care, both supporting practices in how they think about their value-based arrangements by supporting this and talking through what people are doing and in the formulation of a pharmacy services organization, called the [National Cancer Treatment Alliance], to try to be a structure to help practices manage value-based contracting. There's a lot of ways that they've helped.

COA has a second meeting in the fall, which historically has been a payer-provider meeting that's now a payer-provider and innovation meeting to support these initiatives. I do feel like COA is evolving appropriately to try to help practices navigate the change. And I do think in among leaders in community oncology, we all have a fair bit of hustle. We're going to try our best to get out there. But candidly, the work volume is really high and it will pose real challenges to some practices. And I suppose some practices will not sustain these necessary changes.

Mehta: Yeah, and to your point—this shortage issue, there's the physician aspect of it, which is that there's the [doctors] who may not have retired are now retiring earlier than they would have. Mid-career folks like us are not seeing as many patients that we were [seeing], the full 4-day a week, and full clinic is less common. And then the younger folks coming out of med school or residency are not going into clinical practice or don't want to go into full time practice. On top of that, you have nurses that are burned out; I think COVID accelerated a lot of that for them. It's this crisis level that particularly from a rural health standpoint, there's been a little more—thankfully—focus on this rural health and access issues there. Where do you see some of the shifts happening in those places and even [from a] public policy standpoint, what sorts of things are you seeing in investment in rural health?

Patt: Yeah, it's a great question. I do think that rural health is fraught with complications. I do think that the current administration, through CMS policy, has used the power of the pen to have policy changes to make that more sustainable. As an example, I'll say things like making… the COVID changes [permanent] regarding direct virtual supervision. If you have a diagnostic imaging center and you are in a rural area and your volume is low… it's hard to staff that because your doctor that goes to that cancer center also goes to another rural cancer center. They can't be there all the time, not because they're not working, but because the incident to coverage of that diagnostic facility and infusion is complicated. The ability now, at least potentially, to give direct virtual supervision of incident to services allows them when they go to that second rural site to be supervising that first site—that way they can continue to see and to treat patients there even if they're physically not present because they're available on demand. I think that the administration has made important changes in that way that has been really important. That's based on CMS policy that started as of January 1st of this year.

I think that the staffing issue is complex. We have to transform early. We can no longer afford to waste people's time with things that aren't at the top of their license. We need to make sure that we're smartly using our staff in important ways.

Mehta: Yeah, Mondays and Tuesdays I spend in the clinic. I'm at the cancer center and it's a full 18, 19 patients and then the rest of my 10 days a week with Reimagine Care. I think about the virtual model and how that can help, especially in rural medicine. I didn't realize that CMS was expanding that shift. It was great to hear that they're doing that because I think it's going to get worse if they don't.

Patt: Yeah. And…I'm interested to hear about your motivation, but I know for me, my motivation in getting more involved in clinical informatics—and again, I've done clinical decision support for a long time and I'm board-certified in clinical informatics... I led ASCO’s journal for 6 years—my dedication of time and innovation in this space is because I know we need to change, and it's so compelling that…I went into medicine to try to change the world through helping people live longer. I will not be successful in that mission if we cannot change appropriately. That's been really motivating for me personally. I'm curious for you, as you split your time between clinical medicine and Reimagine Care. Can you talk about your motivation to do that?

Mehta: Yeah…like you, I think I saw a lot of the problems early on. My evolution was, I was a personal trainer before I was a physician. I was really into exercise, and I wanted to help the healthiest of people; I wanted to go into sports and orthopedics and that quickly fell off after my first year of med school. I realized it wasn't for me and then decided to go into helping people on the other end of the spectrum, in cancer care and throughout my evolution. I'm board-certified in integrative medicine as well; I started the integrative center there.

But with that came a lot of this misinformation, disinformation of medicine and particularly in oncology. And it just it got to the point where I realized there's only so much I could do in the clinic. And there's so many paradigms that I think needed to be shifted in cancer care and companies like Reimagine Care and others were looking at problems differently. You realize when you're in the clinic, we're looking at our oncologic problems creatively, but I think we're siloed and isolated and problem solving in other ways. I think the last few years since I've been out of that and looking at this differently with colleagues and other companies and other people like you, just the way we solve problems, I think it's good to have the physician at the table in these other places to help shift.

Patt: For sure, yeah. It sounds like you're saying that your scope and scale of influence you could see would be quite different. While clinical care is gratifying every day serving patients, it's one patient at a time. In order to influence more and many, you had to look at it differently. I think that's true. I think that it's my greatest value to community oncology is that I stand at the intersection between these different perspectives: the public policy, the informatics, the business strategy perspective. That's my sweet spot. We need more people in that sweet spot to navigate this change effectively. You and I are a little bit of unicorns in this space. Not everyone does all of that, and we need for people to do that in order for this to work well, because if you try to implement things like digital transformation without a clinical perspective, it will be at your peril, because you need to understand how the clinic works. You need to understand what challenges modern therapies will pose, what burdens they have for patients. I was giving a talk to some of our doctors in Houston on Tuesday night about some of the [datopotamab deruxtecan; Dato-DXd] data, which is really exciting. And I'm excited to be able to offer that to patients, but I said, this is going to create an educational gap because lots of people get mucositis, people get ocular toxicities, and that can be scary, but it's a very effective drug. If we ask, how do we improve upon this, there's a gap of education that we need to solve for. People need to know what to anticipate. We need to be able to prophylax it. They need to know to call if there's a challenge. I'm sure that those toxicities will limit appropriate utilization of an effective therapy, because there are going to be places in the country that are not able to rise to the challenge of those needs of patient education, clinician education, and infrastructure support to manage symptoms. We want it to be better. I think in healthcare more broadly, we need more people to stand at the intersection to say: how do we use modern tools to meet the needs of the evolving practice?

Mehta: Yeah, that's a great segue to our closing here, which is [about] if you had some practical advice to give. Like you said, we need people to do other things. It is difficult to make this change from a pure clinical and administrative research role and then to go into this startup space and learn something new at 50 years old—it's a lot harder to learn at 50 than it was at 30. What advice would you have for, say, leaders in oncology, whether it's a clinician, maybe an administrator? What should they do in the next year?

Patt: I think this year is critical, especially given all of the new AI companies’ interest in healthcare, which is not surprising, of course. I think this year it will be slow and then it will be very fast. I think this is the year [where] it's the call to action for people to really spend time every night in homework, or every day to try to understand this space better and sort of chart the course, if you will. I think of it as like a road map. I call it the road to Nirvana; Nirvana being this perfect practice that we probably will never get to, but we continually strive to be and think how that journey is populated on their road to Nirvana. Do they need to build a virtual care team or do they need to contract with Reimagine Care to offer advanced therapies? Do they need to think about patient self-scheduling? Do they need to develop automated mechanisms for things in their clinic? This is the year to learn that.

I think that you have partners. Again, everyone should attend the COA meeting in April of this year. We're going to have the innovation hub. I think that's going to be incredibly helpful for practices navigating this space. I think ASCO is trying to do a lot too. ASCO has developed a relationship with Google Cloud. They’ve been active on the guidelines. There's already an AI tool to make guideline use much easier. We’ve seen the incorporation of [National Comprehensive Cancer Network] guidelines in OpenEvidence, which is really nice. I think that things are evolving, but I think organizational leaders need to be stepping into the intersection. Oncologists, I feel have homework every day anyway, because like we're constantly drinking from the firehose of new therapeutic innovation, which is a great problem to have, but we're used to having homework every night and having to constantly read up on our profession. I think that we need to think about, the change management and how these new transformation changes will alter our organization and plan for success. That would be my counsel to folks trying to navigate this space.

Mehta: Yeah, that's great advice. I've gotten to chatting with ChatGPT on my drive to and from work if I want to brush up on anything, not necessarily even medical… I'll probably ask ChatGPT about some of the stuff you mentioned around the public policy changes… but yeah. Where's the COA meeting again?

Patt: It's in Orlando.

Mehta: Oh, good. Okay.

Patt: And it’s…at the end of April in 2026. Registration is open. I hope to see you there.

Mehta: Yeah… I'm open. I will be there.

Patt: Wonderful.

Mehta: Great.