WASHINGTON, D.C.—As Congress wrestles with the issue of delivering high-quality, affordable health care in a time of budgetary constraint, the American Cancer Society Cancer Action Network (ACS CAN) hosted a forum here to explore health care delivery reform, especially for patients with cancer and other chronic diseases. Speakers from Congress, the health professions, and economics discussed the use of global bundled payments for chronic diseases; delivery systems with salaried physicians; team medicine; the use of information technology; patient navigation; involving patients more in the costs of health care; wiser palliative care that respects patients' choices; and other cost-effective delivery approaches.
Mark McClellan, MD, PhD, Director of the Engelberg Center for Health Care Reform at the Brookings Institution, said that Brookings will soon release a report on health care delivery reform that endorses moving away from fee-for-service medicine. McClellan is a former administrator of the Center for Medicare & Medicaid Services (CMS) and a former commissioner of the US Food and Drug Administration.
“Our goal was to be a convener,” said ACS CAN President Christopher Hansen. Added John Seffrin, PhD, CEO of ACS CAN as well as the ACS itself, “We realized that the conquest of cancer is as much a public policy issue as a medical and scientific challenge.” There are excellent models of affordable, high-quality U.S. health care, and each is unique,” he said. “Clearly in this country one size does not fit all.”
Asked in an interview if he is concerned about looming budget cuts that will affect cancer research and ultimately delivery of the best cancer care, Seffrin said, “Absolutely. We could literally lose our pipeline of investigators.” If there are federal cuts for cancer research, ACS may have to rethink how it allocates its funds. For example, he said, the Society may have to put more of its money into supporting clinical research investigators.
He noted that ACS CAN data show that more than 300,000 Americans die from cancer each year because they lack access to high-quality, affordable care.
Long-Term Solution for Medicare Physician Payments
Rep. Michael C. Burgess, MD (R-TX), said that some potential good news from Congress is that a long-term solution for Medicare physician payments—instead of an annual short-term fix for the Medicare sustainable growth rate (SGR)—may be implemented this year. Noting that physicians need “a stable, reliable, timely cash flow,” Burgess said, “We should fix that [the SGR], and the good news is this year it may be done.”
“We have a decade before Medicare spends more than it takes in,” said Senator Christopher S. Murphy (D-CT), who was chair of the health committee in the Connecticut state senate before coming to Capitol Hill. “We are going to have a hard, tough conversation about pricing in this country,” he predicted.
He noted that an MRI costs far less in France than it does in the United States, and that there are well-documented regional differences in health costs between parts of the United States (with costs generally less in Hawaii than in New York, for example). Murphy added, “Medicare has to begin teaching best practices, and the Affordable Care Act starts to do that. The delivery system isn't going to change until payments change; I argue that Medicare has to lead the way.”
He predicted that global bundled payments for treatment of a given chronic disease—similar to bundled payments for acute care episodes—may be coming in the future. “It's tougher, but it can be done,” he said.
Change from Siloed Health Care Delivery
The Connecticut senator noted that the United States has a “long, proud history of siloed health care delivery,” and stated that that tradition must change. “Physicians have gotten used to being businessmen,” he said, but he advocated reducing the business aspects of practicing medicine. “Medicine can be fun again if you're just being a doctor and not worrying about insurance forms.”
While stressing the need for health care delivery reform, Murphy raised two cautions: First, health care delivery reforms will depend on the best use of information technology. “Reforms won't work unless you build out the IT system,” he said. “It must be interoperable. If we don't get IT right, nothing will work.”
Second, said Murphy, it would be a mistake to rely too heavily on sick patients to make cost-effective medical decisions: “When you're very sick, in a crisis, or elderly, it's very hard to make decisions that bring down costs. Healthy patients can do that.” So, he said, patients need to participate in medical decision-making before they are too disabled by illness.
Medicare Part D Prescription Drug Benefit a Good Model
McClellan cited the Medicare Part D prescription drug benefit as a model for involving patients in medical decision-making. McClellan, who helped design this program when he was CMS administrator, said that in part because of his Part D experience, “I'm actually very optimistic about where this is all going to end up.”
Initially, some people fundamentally thought the law was a bad idea, he noted. Medicare patients were very confused by the new Part D benefit, and asked, “Why do I have to choose from all these Part D plans?” However, said McClellan, “Once people signed up, they changed the drugs they used,” making wiser medication choices. For example, some changed to lower-cost generics, and they shopped around for the best deals in pharmacies. “What we haven't seen, though, is that kind of involvement hitting other segments of the health system.”
He said he learned the following health reform lessons from implementation of the Part D drug benefit:
* The regulations must be right;
* There must be informational forums to explain the regulations and answer questions from professionals;
* There must be robust data systems;
* There must be educational outreach to consumers on the local level; and
* There must be adaptation in the program when necessary.
Oncology, he continued, is a prime area for health care delivery reform, because cancer survival rates are going up and care is becoming more individualized and personalized with targeted drugs. He said it is not difficult to institute care delivery reforms that can make a big difference, such as health screening reminders and providing worried patients with a professional to call after hours, which can help to avoid visits to the emergency room and hospitalizations.
Oncology Medical Home
He said he favors the oncology medical home concept for cancer patients, because it leads to more coordinated care. He advised the development of specific measures and an infrastructure “to reflect the kind of health system we want,” one that reflects the patient's desires and experience.
He said he also favors financing and regulatory reforms, including use of Accountable Care Organizations: “I think ACOs are a great tool, because they can lead to better value and better health.”
Other Insights & Observations
Among the many other thought-provoking comments at the meeting were the following:
* Cancer patients, especially those in underserved areas, must be diagnosed as early as possible in order to receive the best care—which also saves money. “We know that everybody who has cancer will be treated, unless you're a hermit in the woods; the question is, at what stage will you be treated?” said Harold P. Freeman, MD, CEO and President of the Harold P. Freeman Patient Navigation Institute. Freeman, a former president of the American Cancer Society and a member of OT's Editorial Board, said, “Patients should not die of cancer because they're poor,” and added that it is very important for all patients, but especially for those who are poor, to have navigators who can guide them through the complex health system.
* Consumers need much more information on health costs and outcomes if they are to participate in making wise medical decisions. “The system is incredibly non-transparent,” said Michael Kolodziej, MD, Aetna's Medical Director of Oncology Solutions.
* When patients have been given information on their treatment choices, their decisions should be respected if reasonable—even if different from those of their physician, said Amy Berman, RN, Senior Program Officer at the John A. Hartford Foundation. She was diagnosed with Stage IV inflammatory breast cancer and has opted for a less aggressive treatment than her physician advised. “I feel good; I get to do all the things I want to do,” she said. “I'm not dying; I am living with serious illness.”
* There needs to be much more emphasis on disease prevention to lower the risk of cancer and other chronic diseases. “We have to put a lot more emphasis on lifestyle in the next few years,” said Joanne Schottinger, MD, a medical oncologist who is Assistant Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group (SCPMG). No longer will it be acceptable for physicians within SCPMG to tell patients to lose weight; the physicians will have to refer obese and overweight patients to evidence-based weight management programs that have nutritionists and other trained professionals.
* While it is fine for patients to play a larger role in health decision-making, physicians cannot abdicate their responsibilities for the final treatment decision. For example, said Peter Bach, MD, Attending Physician in the Epidemiology & Biostatistics Health Outcomes Department at Memorial Sloan-Kettering Cancer Center, a patient may come in and demand a certain treatment. “A physician should not simply accede to that demand if it is not the right decision.”