VALUE IN ONCOLOGYPROBLEMS, SOLUTIONS & AN EXPERIMENT

Derek Raghavan MD PhD FACP FRACP FASCOPresident, Levine Cancer Institute

ASSOCIATION OF CANCER EXECUTIVES, January 2014

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PHILOSOPHY OF CANCER TREATMENT

Cure when possible

Maximize length and quality of life

Pioneering in science

• Laboratory to clinic

• Clinic to laboratory

Care of the patient and family

Rationalize costs when possible and ethically sound

LET’S START WITH HEALTH CARE IN GENERAL IN THE U.S.A.

WHAT ARE THE KEY PROBLEMS

THAT RELATE TO ONCOLOGY?

HEALTH CARE: THE GOVERNMENT SHELL GAME

The U.S. population has “expectations” for health care

Nobody is interested in health care unless illness involves them – patients, families, friends (somewhat)

Governments cannot afford to provide the care that the population expects

NOBODY wants to pay for health care

Lobbyists lobby

Why did the Oregon experiment fail?????

A SHARED RESPONSIBILITY

The population and health behavior – smoking, obesity

Death is an un-American activity

The medical profession – profits, fear of litigation, lobbying

The pharmaceutical industry – profits, lobbying

Politicians

The legal profession – profits, lobbying, stirring the pot

Health Care Spending by Country

Percent of GDP (2008)

Source: 2008 Data from the Organization for Economic Cooperation and Development.

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Factors Influencing Oncology Practice

Community expectations

– General, the press

– Specific, patient satisfaction

Trajectory of change of outcomes

Pace of the science

Multiplicity of clinician constituencies

Learned Societies

Changing Demographics

Government

– Legislation

– Funding for Research

– Payment for services/Medicare/etc.

– Government as a provider

Reimbursement changes

• Payers/Insurers

• Employers

Organized Research Groups

Advocacy Organizations

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Community Expectations

The Press – cancer a “hot” topic

“War on Cancer” generated false expectations, regularly revised as false expectations

Driven by politicians

Driven by experts with/ without skin in the game

• Dartmouth

• Ethicists

Leapfrog, Press Ganey & clones – patient surveys

Conflicts of interest in government evaluations

Health Policy “experts”

Influence of advocacy groups

• Tension between science and opinion?

• Influence of opinion leaders

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Community Expectations

The Press – cancer a “hot” topic

“War on Cancer” generated false expectations, regularly revised as false expectations

Driven by politicians

Driven by experts with/ without skin in the game

• Dartmouth

• Ethicists

Leapfrog, Press Gainey & clones

Conflicts of interest in government evaluations

Health Policy experts

Influence of advocacy groups

• Tension between science and opinion?

• Influence of opinion leaders

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What’s thedeal in NH?

What’s upin LA?

What’s The Story in NH and LA

NH:

• Small area

• Educated

• Fewer indigent

• High density academics

• High density proximate hospitals

• Dartmouth engineers of healthcare

• Work conditions

• Liberal state

LA:

• Poverty

• Large state

• Poor access

• Poor education

• African American cultural issues

• Targeting of advertisers

• Work conditions

• Conservative state

5 WORST STATES FOR HEALTH INSURANCE

TEXAS

NEVADA

ALASKA (“I can see Russia from my kitchen!” Tina Fey 2008)

FLORIDA

GEORGIA

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Don’t Forget the Centers that “Skim”

Medicare

Medicaid

Need Not Apply!!!

Strategy for Health Plans (Porter & Teisberg, 2006)

Provide health information and support to patients/physicians

• Organize around medical conditions, not geography or administrative functions

• Provide comprehensive disease management/prevention services for all members, healthy or unhealthy

• Provide information and transparency regarding outcomes

Restructure the health plan – provider relationship

• Reward excellence/innovation

Redefine the health plan – subscriber relationship

• End cost-shifting practices

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BOTTOM LINE OF A SENSIBLE APPROACH

PARTNERSHIP

INVOLVE KEY STAKE HOLDERS

FUNCTIONALLY DRIVEN

COMPREHENSIVE

TRANSPARENT

REWARD EXCELLENCE

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Government

Consumer

– Federal

– State

– Local

Payer

Research

Regulator

Examples:

• NCI

– Regulates research

– Regulates centers

– Funds research

– Funds cooperative groups

– Does research

• FDA

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Remember those little politicians!!

Trajectory of Change of Outcomes vs Expectations

Changing Endpoints

• Survival

• Quality of life

• Cost

• Patient satisfaction

• Molecular targets

• (Not well connected to community expectation)

“Hype”

Institutional advertorials

Meetings & abstracts

Real progress

• Peer reviewed publication

• National survival statistics

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Proposed Strategic Approach to Cut Health Care Costs

Stay on top of the science

Integrate clinical trials with rational design and careful costing

Manage across the system

• Porter & Teisburg

• Avoid skimming

Reduce unnecessary tests

Blue ocean/Red ocean strategy

Rational selection of treatment:

• Outcomes should drive

• Strong scientific rationale

• Structured palliative care

Measure and present robust outcome data

Listen to the lay evaluations, but structure them carefully

Don’t listen to everyone

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My Strategy Physicians and bio-medical organizations reduce costs

Address tort reform in a meaningful way – costs to system are VASTLY under-estimated

Provide a safety net – especially for chronic disease and those who run out of health insurance

Improve access

Re-educate the community about realistic expectations

Require training for those who tinker with the system

Reward excellence

Transparency

Refine costs of biomedical development

SO…Where does Levine Cancer Institute fit?

Addressing costs and inconvenience of care

Attracting new expertise to the region

Bringing research to this area

A new model of patient support

Standardization and evidence based approaches

Symmetrical care across the Carolinas – for everyone!

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The Levine Cancer Institute will be recognized by cancer patients and their families, referring physicians, and the communities we serve as the “first choice” provider in the Carolinas and the Southeast, and further renowned as one of the premier cancer care providers in the country.

Unified cancer network – concept of “ONE-ness” in 2011

personalized service

high quality outcomes

Clinical trials and access to research/screening/navigation/palliative services

Collaboration enterprise-wide to

Enhanced quality

Enhanced access

Each CHS patient entry point will be a portal into a network of specialized services

Incorporation of translational research

NATIONAL/INTERNATIONAL presence

INITIAL CONCEPT: VISION STATEMENT

Our Vision – Changing the Course of Cancer Care

Unified enterprise-wide network

Spread across two states

Patient-centered

Connected across the enterprise

Clinically integrated

Best-practice collaboration across the

enterprise

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Structure for Enterprise Engagement & Collaboration

Enterprise SummitsEducation, Networking/Team Building

Enterprise Cancer Strategy CouncilCoordination of Enterprise Cancer Initiatives

CharlotteRegional Cancer

Strategy Council

WesternRegional Cancer

Strategy Council

LowcountryRegional Cancer

Strategy Council

UpstateRegional Cancer

Strategy Council

Market Development, Regional Tumor Site Planning & Development

2x/Year

Quarterly

Monthly Tumor Site Team Quality

Council

May 13,2011

Launch by May 2011

Launching March-April,2011

Algorithm Developed by “Oncology Solutions”

Levine Cancer Institute: Charter Members

An-Med, Anderson SC

Blue Ridge, Valdese NC

Carolinas Medical Center

Cleveland Regional Medical Center, Shelby NC

Lincolnton Hospital

Mercy Hospital, Charlotte NC

Northeast Hospital, Concord NC

Pineville Hospital, Pineville NC

Roper St Francis Hospital, Charleston SC

Stanly Regional Medical Center, Albemarle NC

University Hospital, Charlotte NC

Union Hospital, Monroe NC

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Levine Cancer Institute Membership Criteria

Central IRB – Chesapeake

Local 0.1 FTE leader

Staff participation in tumor boards/conferences

E-treatment pathways

Patient Navigation

SOP’s and quality

Clinical trials infrastructure

Participation in survivorship programs

Complementary/integrative cancer medicine program

E-genetic counseling

Disparities program

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Recruitment

100+ thus far

• 50 locally

• 50 nationally

Academic programs – clinician investigators

Clinical programs

Moving from general to sub-specialty practice

Integration of staff – no second-class citizens

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PROGRAMS

INNOVATIONS IN PROGRESS

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MelanomaStage IV OR unresectable Stage III

Distant metastatic disease OR

UNresectable Stage III

Patients should be considered

for multidisciplinary

discussion to determine

potential for surgical

resection

See Follow-up Stage IV

NED

SurgicalResection

Resectable

Treatment

Disseminated(Unresectable)

IL-2 Candidate

Clinical TrialIpilimumab

Chemotherapy

Clinical TrialIpilimumab

BRAF inhibitionChemotherapy

SRS +/- WBRT

Clinical trial or Observation

BRAF +

BRAF -

• Biopsy of distant disease

• LDH• CT C/A/P & MRI

brain OR PET/CT• Path for BRAF

mutation

Without brain metastases

BRAF +

BRAF -

With brain metastases

Not an IL-2 candidate

Phase II BMS

Phase II Roche MO25743

PROCLAIM Registry

SELECT DFCI

ECOG 1609Adj Ipi vs IFN

Trial NEEDED

Edward S. Kim, MDChair, Solid Tumor Oncology

“Monthly Section Meetings”

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Survivorship

Survivorship Program

• Identification via Tumor Registry and Physicians

• Structured algorithms

• Engagement of medical staff of system hospitals & practices

• Engagement of key physicians for patients

• Administrative system-wide structure

• Examples:

– Long term survivor after radiotherapy for breast cancer

– Long term survivor after chemotherapy for metastatic testis cancer

– Psychological issues

– Kids who are now grown-up’s

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Levine Oncology Program for Seniors

• Years 3-4

• Geriatrician in place & support base in development

• Specific oncology personnel – Daniel Haggstrom MD, Raghava Induru MD

• Established track record of published data

• Focus on the WELL-ELDERLY

• Based at Mercy Hospital and Stanly Hospital

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Cancer Flying Squad

• Led by Dennis Devereux MD (Stanly) & Mike Lutes (Union)

• Sub-specialty home services

• Building towards home chemo/tumor measurements/transfusion

• Helps with early discharge

• Reduces Average Length of Stay

• Reduces re-admissions

• Sensible fiscal model – patients who won’t come to hospital

• The right thing to do

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Integrative Cancer Medicine Program

• Leadership: Chasse Bailey-Dorton MD, Wendy Brick MD (in future?)

• Structured studies

• Broad options – music therapy, art therapy, diet, etc.

• Provision of accurate information

• De-criminalization for up to 50%

• Clinical trials

• Education for patients on early phase trials

• Pastoral Care Academy – David Carl – 25 CHS pastors, October 2012

Evolution, 2012-2013

12 Levine Cancer Institute participating groups

Phase I clinical trials unit(s) in progress

Phase II clinical trials – based throughout CHS

Tumor Specific Teams

Educational courses

Leadership at Roper/St Francis

Navigator Academies 1 and 2

Single Tumor Registry

Treatment pathways/protocols

Administrative team in place

Academic leadership identified

Cancer pharmacology lab team

HOT lab

Hem/Onc fellowship planning

Cancer Emergency Dept Network

Survivorship initiatives

Patient satisfaction/value/cost

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Potential Impact of Levine Cancer Institute(work-in-progress)

Care near home – less travel, accomodation, time

Evidence-based standard approaches

Optimal support – navigation, survivorship

E-genetic counseling

Focused cancer research and clinical trials

Resources spread through the system – ALL patients

Electronic support – tumor boards, video conferences, access

Cost Containment – Broader Efforts

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EXPERIMENT: ARE THE FOLLOWING IMPROVED?

QUALITY

• via standardized, evidence based pathways

• System-wide tumor conferences, education, pathway design

• System approach to drug shortages

IMPROVED COST

• via pathways, trials, access, less travel

• Integrated selection of palliative/supportive care

• Trial selection linked to clinical practice section policy

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Early Evidence

Press Ganey – 99% System-Wide for LCI

Commission on Cancer – 8 programs, all with max. merit

QOPI

External Advisory Board – no concerns

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Proposed Strategic Approach to Address Health Care Costs

Stay on top of the science

Integrate clinical trials with rational design and careful costing

Manage across the system

• Porter & Teisburg

• Avoid skimming

Reduce unnecessary costs

Blue ocean/Red ocean strategy

Rational selection of treatment:

• Outcomes should drive

• Strong scientific rationale

• Structured palliative care

Measure and present robust outcome data

Listen to the lay evaluations, but structure them carefully

Don’t listen to everyone

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