BOSTON—“No one is dealing with the underlying problem,” the keynote speaker said. “We're not worried about the total size of the check. We have to focus on the overall cost of the system.”
The costs, quality, and accessibility of American health care were the focus of the first keynote address from Arthur L. Kellerman, MD, MPH, the Paul O'Neill-Alcoa Chair in Policy Analysis at the RAND Corporation, here at this year's American Society for Radiation Oncology Annual Meeting. And, concern about the high price of health care in the U.S. were central also to two additional keynote addresses at the meeting, as well as a 40-minute talk by the organization's 2011-2012 President and Chairman of the Board of Directors, Michael Steinberg, MD, FASTRO.
The message to ASTRO members and meeting-goers: it's up to providers, as well as Washington, now to make health care delivery in the U.S. sustainable and affordable.
The Underlying Harms
“According to many politicians in both parties, we have the finest health care system—but, do we?” asked Kellerman. “We're spending too much money, we've got not so great quality, we're not giving people the care they need 45 percent of the time, and we've got real access problems.”
Problem one, the U.S. spends more than any other country on health care, he explained, citing the following statistics:
* The rate of workers in the U.S. with employer-sponsored health insurance fell 10 percent in the last 10 years.
* The average American family was paying $5,400 more in 2009 on health care than in 1999—accounting for out-of-pocket costs, deficit spending, and income not earned. “American medicine spent that money ordering tests, ordering treatments—doing what we do—more expensively than the year before and the year before that,” Kellerman said.
* The U.S. outspends other high-income countries like Canada, Australia, New Zealand, and parts of Western Europe per person on health care. And, in the middle of a recession in 2009 while American business in the financial sector was on the brink of collapse, health care spending that year was up 3.8 percent.
The health care industry in the U.S. does not respond to the usual economic signals that govern the rest of the market, Kellerman said. “Friends, that's a problem. This is having real consequences for the other parts of the U.S. economy.”
And problem two, he explained: For a much higher price, quality of care is dropping. Data collected on patients in 12 metropolitan areas in the U.S. showed that patients received recommended care for chronic conditions like diabetes, asthma, influenza, and hypertension, just 55 percent of the time, he said, citing a New England Journal of Medicine study in 2003 (348:2635-2645).
Life expectancy has increased by one year in that 10-year period; but life expectancies in other countries spending less money on health care increased by 2.2 years, Kellerman continued. And data show the U.S. has some of the highest rates of amenable mortality in the world, he noted. “We're losing too many people from [diseases] we know how to treat today.”
The third problem is access. A greater percentage of Americans choose not to get the care they need (because of how expensive it is) than do populations in the UK, the Netherlands, Switzerland, France, Canada, and Germany, he said, citing a 2011 Commonwealth Fund study.
Physicians need to be part of the solution, Kellerman said, noting that a recent Institutes of Medicine's report said that U.S. health care wastes $750 billion a year on unnecessary inefficient services, excessive administrative costs, high prices, medical fraud, and missed opportunities for prevention. “We can do a lot with $750 billion,” he said.
Efforts like ASTRO's “Best Practices” initiatives (www.astro.org/Clinical-Practice/Best-Practices/Index.aspx) need to be part of the solution, he explained. “You're using a rational, evidence-based, specialty-driven process to take the best, most rigorous, scientific evidence; putting it through an objective, transparent, expert-consensus process; and identifying care that is highly necessary and highly appropriate for a given condition. You define that—not a federal bureaucrat, not insurance executive—but you do it as a collective body of committed, scientifically rational professionals.”
We must eliminate the waste and efficiency of the current system—by giving patients a financial stake in managing their care (by adjusting copays and deductibles) and by delivering “value instead of volume” in health care, he said. “The ball is in your court: you need to be a part of that solution.”
Urging Action and Involvement
The second keynote address, by Edward M. Kennedy, Jr., President and Co-founder of the Marwood Group (a New York City-based health care strategic and financial advisory firm), had the title “Future Trends in Cancer Survivorship,” but Kennedy diverged to remind ASTRO members and other meeting-goers of their needed role in health care reform.
There is a responsibility to stay informed and involved, he said. “Radiation oncologists and their allied professions need to stay on top of these issues and figure out how to adopt these trends—particularly the principles of bundling. And, there's no room for partisanship: There are a lot of practical solutions, but the problem is that a lot of the time, we just can't give the other team credit for coming up with a good idea—that's part of the problem.”
Kennedy, a nearly 40-year survivor of osteosarcoma, urged the physicians in the room to take action: “Go home, call and write to your representatives. People don't know whom to believe in Washington because they're bombarded with messages. They're starved for people who are in real-life practice who can speak to real-life experiences—just the kind of experiences that every single person in this room has.”
Where Radiation Oncology Sits
The following day, in his Presidential Address, Steinberg explained why—for radiation oncology right now—improving the system is crucial. “Here we sit, undeniably as a technology-based specialty, at the peak of our game, in the midst of a national discussion about how the rising cost of health care is not economically suitable for our country,” he said. “But, this is more than a health policy debate—for us this is a health policy debate about how our specialty will survive in the future.”
Across medicine, he continued, the misuse and corruptive use of appropriate therapies, a payment system that incentivizes volume over best practice, physician self-referral, and disparity in care put the health care delivery system in disarray.
The general consensus of health policy experts is that as much as 30 percent of care delivered in the U.S. is duplicative and unnecessary and may not improve people's health, he noted. Plus, the trends of population growth (particularly in the elderly), increasing minority populations, and increasing physician shortages will make solutions to the health care cost crisis only more difficult.
And specifically there's an increasing underutilization of radiation oncology, even when it may be the most appropriate care, a phenomenon Steinberg referred to as “the patient not treated.” “Is this a phenomenon of patients simply receiving what is perceived to be new cutting edge technology?” he asked.
There has been a substantial rise in prostatectomy since the mid-1990s (particularly with the emergence of robotic surgery), despite the success proven for intensity-modulated radiation therapy (IMRT) to treat prostate cancer, he said.
Similarly for breast cancer: There is an increasing trend toward the use of mastectomy, MRI, and genetic testing, as well as newer reconstructive surgical techniques, even though there is a lack of evidence proving the superiority of the new procedures over radiation therapy, he said. For example, he noted, Moffitt Cancer Center reported a 30 percent drop in the rate of breast-conservation surgery from 2003 to 2007.
Radiation oncologists need to play offense, he said. ASTRO is already taking the lead: The board formed a radiation-biology task force, which evaluates existing research, sets future research and education priorities, and suggests a translational agenda to ensure ongoing development of the specialty; and has initiated a grant to support comparative effectiveness research in the specialty.
ASTRO will also participate in the American Board of Internal Medicine Foundation's Choosing Wisely Initiative, he announced. (A note on the ABIM Foundation website now includes ASTRO in the list of organizations expected to release their specific “Five Things Physicians and Patients Should Question” by the middle of 2013.
“This exercise will not be about self-promotion, but rather about proving the value of what we do—and if what we do is not truly valuable, we will say that,” he said. “At some point, as the stewards of our health care system, we must take a stand about what is right for patients and what is right for our health care delivery system.”
And on the final day of the meeting, Michael E. Porter, PhD, MBA, the Bishop William Lawrence University Professor at Harvard Business School, spoke about the solution to delivering that higher quality care. “Ultimately we're going to succeed based on the value we need to deliver,” he said.
A restructuring of the delivery of health care in the U.S. is already well on its way, but the challenge still remains to make sure the changes are on the path to improve value—and the first step is getting the definition of “value” right, he said. It's not the ultimate outcome or the procedure outcome that matters, he said: “It's the outcome from the whole cycle of care for the patient's problem that really matters.”
Adding care coordinators to help users navigate a fundamentally flawed system will not work, he said. “Ultimately we need to change the structure so you don't need a care coordinator—so that care coordination is embedded in the way we organize our care delivery processes.”
The U.S. has been competing in the wrong areas of health care delivery, Porter maintained. “We've been competing to aggregate bargain of power, get a higher reimbursement, shift cost to someone else, and capture patients so that we'll get the referrals, rather than what we must do, which is compete on delivering the highest value for the patient.”
He outlined six steps that will move health care delivery into a value-based system (see box). The first step is critical, he said: “We need a team that takes overall responsibility for the entire care of the condition, rather than just for the piece of the care that they provide.”
He also explained approaches to change the reimbursement model—price bundling (which puts an emphasis on the end solution to the patient's problem, rather than paying for all the individual pieces to get there) and local capitation (fixed prices for a given medical problem). Models of the later used in Sweden reduce the costs of some procedures to a third of those in the U.S.—and the physicians did not get paid less, Porter said.
He concluded, like Kellerman, by reminding the audience of their role in making the changes necessary: “Is your organization on this journey? Have you started down the path to add value?”
6 Steps to Putting More Value in Health Care
Michael E. Porter, PhD, MBA, of Harvard Business School recommended the following key changes:
1. Restructure delivery to organize the system around the need (the patient's problem), not around the tool used to practice.
2. Measure outcomes routinely and comprehensively (including costs) while care is delivered, not retrospectively (which takes too long and doesn't yield enough measurement.
3. Change the reimbursement model so that payments are made for the total package of care, not for discreet services.
4. Tie together care centers into collaborative systems and partnerships, rather than stand-alone units working independently.
5. Distribute expertise of care more evenly across the country, not just in Centers of Excellence.
6. Find the right information technology to allow more efficiency in managing patients and tracking outcomes.