The Changing Oncology Landscape: Evolution or Revolution?

May 2013, Vol 4, No 4

Hollywood, FL—Panelists at the 2013 National Comprehensive Cancer Net­work (NCCN) annual conference view the oncology world as rapidly changing, and the impact of this, for better or for worse, will be felt by healthcare providers, payers, and patients alike.

“Certainly, this landscape is shifting beneath our feet,” said Clifford Goodman, PhD, Senior Vice President and Principal, the Lewin Group, a healthcare consulting firm in Falls Church, VA, who moderated this panel discussion. “There are tectonic forces, and these are unsteady times,” Dr Goodman said.

The Coverage Conundrum
The US population is not getting any healthier, despite broadening access to care and efforts to eliminate disparities, the panelists agreed. This is largely because the socioeconomic gap is widening and healthcare is becoming less affordable. “In 3 years, the person who makes an average US salary will have to spend 50% of it to cover his out-of-pocket expenses and healthcare premium,” Lee N. Newcomer, MD, MHA, Senior Vice President, UnitedHealthcare Group, Minneapolis, MN, pointed out.

John L. Fox, MD, MHA, Senior Medical Director, Priority Health, Grand Rapids, MI, further predicted, “In the future, there will be healthcare exchanges and subsidies for low-income persons, but the middle class may be squeezed. Their out-of-pocket costs could be up to $6000 for an individual or $12,000 for a family. Even Medicare and Medicaid will experience more cost-sharing. This is a new disparity.”

One result of this is a population of persons who bypass preventive care and screening, and thus enter or re-enter the workplace with a higher risk profile or more advanced disease. Susan A. Higgins, MD, MS, Associate Director, Department of Therapeutic Radiology Residency Training Pro­gram, Yale Cancer Center, New Haven, CT, added that in her practice at Yale, she is seeing stage IV cervical cancer (a “third-world country disease”) among her underprivileged patients. In contrast, her affluent patients are moving into concierge practices. Although the Affordable Care Act will “ballast the very bottom,” Dr Higgins said, high copays for everyone else means that “the bottom of the middle class is falling down.”

Roy A. Beveridge, MD, Chief Medical Officer, McKesson Specialty Health, predicted that healthcare reform will increase coverage for previously uninsured persons, “but it is going to create other types of problems for how we care for them.”

Dr Newcomer predicted that reform will broaden access to care, but it will not affect the escalating cost of care. “Access may not be worth much if people cannot afford the deductible,” he pointed out.

Involving the Patient
Greater attention must be paid to early integration of palliative care. Dr Fox suggested that before cancer outcomes can be improved, oncology stakeholders need to determine “which outcomes are most valuable.” At Priority Health, he said, the outcomes are “those that are most valuable to our patients,” and this is not necessarily longer life expectancy.

The patient’s list of priorities must be front and center of clinical decision-making, and any treatment should be consistent with them. “The only way to know this is to ask the patient,” Dr Fox said.

Dr Beveridge saw other obstacles to the successful integration of palliative care or end-of-life care: the lack of manpower to effectively deliver it, and the fact that patients often fail to grasp its meaning. “Patients don’t want to make their caregivers unhappy. We have found in interviews that many will accept a third or fourth line of futile therapy, because they don’t want to let their doctors down. Interestingly, physicians say they are giving futile therapy because they don’t want to let their patients down,” he said.

Dr Newcomer called this a “philosophical barrier.” “Americans still think death is an option,” he said. “We have a whole culture that says it is wrong to stop [treatment],” and this impedes a full and open exchange about prognosis.

“When you throw in the family and cultural dynamic, you almost need the Department of State as a negotiator,” Dr Beveridge added. “We have found that it is frequently better to have a nurse practitioner or social worker introduce the topic, because we as physicians are not trained to do this, and we don’t do it particularly well.”

Tools to help initiate these discussions are becoming available, including the American Board of Internal Medicine Foundation’s Choosing Wisely initiative, which includes the American Society of Clinical On­cology’s “Top Five” list of common, costly procedures in oncology that are not supported by evidence and that should be questioned. Some practices in the UnitedHealth Group network are asking patients to complete the Choosing Wisely form on hospital admission. “These practices are achieving much more patient-oriented outcomes, far fewer days in the ICU [intensive care unit], and more deaths at home, because they are having this discussion,” Dr Newcomer reported.

Dr Newcomer said that he recently used the Choosing Wisely tool with his own parents and was surprised at what he learned. “I changed my viewpoint about their end-of-life care. This can be done,” he stated. “It doesn’t require an army of palliative care specialists but a cultural commitment.”

How to Brave the New World: The Evolving Ecosystem
The future of cancer care requires a reformed “ecosystem,” in the words of Dr Goodman. This means the integration of components in a multidisciplinary approach and a competitive collaboration to problem solving.

The evolving ecosystem is no longer centered on individual excellence but rather on interoperable performance. “We were trained to play golf. The game has switched to basketball,” he said. “It’s about interoperability [and] how to work together, so that I can’t be as good as I need to be without Lee Newcomer,” said Andrew C. von Eschenbach, MD, President of Samari­tan Health Initiatives, Montgomery, TX, and Adjunct Professor, M.D. Anderson Cancer Center, Houston, TX.

Dr Goodman noted that Dr von Eschenbach once headed the National Cancer Institute, which included “many competing cancer institutions doing research.” Dr von Eschenbach said that the ideal scenario would not have been “61 separate phenomenal cancer centers, but 61 playing together like a well-orchestrated team.”

“As we look toward a brave new world in oncology, it’s tempting to look at all the high-tech stuff we have for discovering the next cure. But in this roundtable, we saw that in order to get to the next level, we can’t forget that we have disparities in care that drag the system down,” Dr Goodman said. “We need to hold up that part of our at-risk population at the same time we advance the cutting edge with big data and reorganizing the cancer ecosystem. Our current incentives and disincentives are not providing for optimal care.”

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