Panelists at the 2013 Annual Conference of the National Comprehensive Cancer Network (NCCN) 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 of the Lewin Group, a healthcare consulting firm based in Falls Church, Virginia, who moderated the panel discussion. “There are tectonic forces, and these are unsteady times,” he said.
The population in the United States 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, especially to the middle class. “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, senior vice president of UnitedHealth Group, Minneapolis, Minnesota, pointed out.
John Fox, MD, MHA, senior medical director of Priority Health, Grand Rapids, Michigan, 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 reenter the workplace with a higher risk profile or more advanced disease. Susan A. Higgins, MD, MS, associate director of the Department of Therapeutic Radiology Residency Training Program at Yale Cancer Center, New Haven, Connecticut, 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. While the Affordable Care Act will “ballast the very bottom,” Higgins said, high copays for everyone else means “the bottom of the middle class is falling down.”
Roy Beveridge, MD, chief medical officer of 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.”
Newcomer predicted it will broaden access to care but 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, both for quality-of-life reasons and as a way to reduce the cost of end-of-life care. Fox suggested that before cancer outcomes can be improved, oncology stakeholders need to determine “which outcomes are most valuable.” At Priority Health, he said, they 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,” Fox said.
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.
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,” 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 program, 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 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,” Newcomer reported.
He 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,” Newcomer said. “It doesn’t require an army of palliative care specialists but a cultural commitment.”
Some employers are beginning to see the value of palliative care and have expanded benefits accordingly. Some are even subsidizing advanced care directives and living wills. “At Pitney Bowes, we provide incentives for this,” offered John J. Mahoney, MD, MPH, consultant to Pitney Bowes.
How “Big Data” May Personalize Medicine
“Big data” will revolutionalize cancer care, panelists predicted. The power of tools like Watson is already being realized, said Marty Kohn, MD, MS, of IBM. Watson is a computer learning system that self-corrects and self-improves with little human input. “Watson can read and comprehend thousands of articles in a few seconds,” according to Kohn.
Watson’s future role in therapeutic decision-making can be demonstrated in a joint venture between Memorial Sloan-Kettering Cancer Center and WellPoint. Watson is being taught to understand the critical attributes of a cancer patient’s history, to consult the literature and evidence-based guidelines, and to come up with treatment recommendations.
But big data and tools like Watson do far more than accumulate information, Kohn pointed out. They draw from multiple pathways to create a basis for making personalized decisions that are more likely to have value. It is not just “lots of data” but data that encompass volume, velocity, variety, and variability.
More real-world than Watson was the example given by Newcomer, who noted that UnitedHealth Group has access to a decade’s worth of information on 70 to 80 million people that can be integrated with state tumor registries and insurance claims data to create longitudinal records for individuals. This will be used to profile chemotherapy regimens and their progression-free survival rates, he said. He expects this registry to be a more realistic picture than is gained from clinical trial data and to be useful to third-party payers in determining coverage.
Among the panelists, Andrew von Eschenbach, MD, president of Samaritan Health Initiatives, Montgomery, Texas, and adjunct professor at MD Anderson Cancer Center, Houston, Texas, was particularly enthusiastic. “Big data is the most critically important thing we could be talking about,” he said. “If we have any hope of improving outcomes, it’s in the big data.”
The capturing of big data will revolutionize basic research and allow for modeling in silico cellular processes, biological processes, and multiple oncologic pathways. In clinical research, big data will allow for more sophisticated analyses that will “move us from information to real knowledge,” von Eschenbach predicted. “Then, with physician engagement and interpretation, we get to wisdom,” he said, which should lead to the ultimate goal of giving the right treatment to the right patient for the right reason. “That is the difference between rational medicine and rationed medicine.”
Others on the panel were more cautious. “The trick is not to acquire data alone,” according to Beveridge, but to assure that the integrity of the data is strong. Fox emphasized that data should not be used “in a vacuum,” but in the context of patient preferences, which may include no active intervention. “We think about how to improve overall survival, but the challenge is for us to think differently. Overall survival is not the sine qua non of cancer care.”
How to Brave the New World:
The Evolving Ecosystem
The future of cancer care requires a reformed “ecosystem,” in the words of 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,” von Eschenbach 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.”
Goodman noted that von Eschenbach once headed up the National Cancer Institute: “many competing cancer institutions doing research.” The ideal scenario, von Eschenbach said, 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,” Goodman concluded. “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.”
Goodman C, Beveridge R, Fox J, et al. The changing oncology landscape: evolution or revolution? Presented at: 2013 Annual Conference of the National Comprehensive Cancer Network; March 15, 2013; Hollywood, FL. Roundtable discussion.