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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