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VALUE IN ONCOLOGY
PROBLEMS, SOLUTIONS & AN EXPERIMENT
Derek Raghavan MD PhD FACP FRACP FASCO
President, Levine Cancer Institute
ASSOCIATION OF CANCER EXECUTIVES, January 2014
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
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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
 Government
– Legislation
– General, the press
– Funding for Research
– Specific, patient satisfaction
– Payment for services/Medicare/etc.
 Trajectory of change of
outcomes
– Government as a provider
 Reimbursement changes
 Pace of the science
 Multiplicity of clinician
constituencies
 Learned Societies
•
Payers/Insurers
•
Employers
 Organized Research Groups
 Advocacy Organizations
 Changing Demographics
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Community Expectations
 The Press – cancer a “hot”
topic
 Leapfrog, Press Ganey &
clones – patient surveys
 “War on Cancer” generated
false expectations, regularly
revised as false expectations
 Conflicts of interest in
government evaluations
 Health Policy “experts”
 Driven by politicians
 Influence of advocacy groups
 Driven by experts with/
without skin in the game
•
Dartmouth
•
Ethicists
•
Tension between science and
opinion?
•
Influence of opinion leaders
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Community Expectations
 The Press – cancer a “hot”
topic
 Leapfrog, Press Gainey &
clones
 “War on Cancer” generated
false expectations, regularly
revised as false expectations
 Conflicts of interest in
government evaluations
 Health Policy experts
 Driven by politicians
 Influence of advocacy groups
 Driven by experts with/
without skin in the game
•
Dartmouth
•
Ethicists
•
Tension between science and
opinion?
•
Influence of opinion leaders
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What’s the
deal in NH?
What’s up
in LA?
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What’s The Story in NH and LA
 NH:
 LA:
•
Small area
•
Poverty
•
Educated
•
Large state
•
Fewer indigent
•
Poor access
•
High density academics
•
Poor education
•
High density proximate hospitals
•
African American cultural issues
•
Dartmouth engineers of healthcare
•
Targeting of advertisers
•
Work conditions
•
Work conditions
•
Liberal state
•
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
Remember those little politicians!!
Consumer
– Federal
Examples:
• NCI
– State
– Regulates research
– Local
– Regulates centers
Payer
– Funds research
– Funds cooperative groups
Research
Regulator
– Does research
• FDA
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Trajectory of Change of Outcomes vs Expectations
 Changing Endpoints
• Survival
• Quality of life
 “Hype”
 Institutional advertorials
 Meetings & abstracts
• Cost
• Patient satisfaction
• Molecular targets
 Real progress
•
Peer reviewed publication
•
National survival statistics
• (Not well connected to
community expectation)
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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
 Rational selection of
treatment:
•
Outcomes should drive
•
Strong scientific rationale
•
Structured palliative care
 Measure and present robust
outcome data
 Reduce unnecessary tests
 Listen to the lay evaluations,
but structure them carefully
 Blue ocean/Red ocean
strategy
 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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INITIAL CONCEPT: VISION STATEMENT
 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
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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
May 13,2011
Enterprise Summits
2x/Year
Education, Networking/Team Building
Enterprise Cancer Strategy Council
Quarterly
Launch by
May 2011
Coordination of Enterprise Cancer Initiatives
Launching March-April,2011
Monthly
Charlotte
Regional
Cancer
Strategy
Council
Western
Regional
Cancer
Strategy
Council
Lowcountry
Regional
Cancer
Strategy
Council
Upstate
Regional
Cancer
Strategy
Council
Tumor Site
Team Quality
Council
Market Development, Regional Tumor Site Planning & Development
Algorithm Developed by “Oncology Solutions”
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Levine Cancer Institute: Charter Members
 An-Med, Anderson SC
 Northeast Hospital, Concord NC
 Blue Ridge, Valdese NC
 Pineville Hospital, Pineville NC
 Carolinas Medical Center
 Roper St Francis Hospital,
Charleston SC
 Cleveland Regional Medical
Center, Shelby NC
 Stanly Regional Medical Center,
Albemarle NC
 Lincolnton Hospital
 University Hospital, Charlotte NC
 Mercy Hospital, Charlotte NC
 Union Hospital, Monroe NC
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Levine Cancer Institute Membership Criteria
 Central IRB – Chesapeake
 Clinical trials
infrastructure
 Local 0.1 FTE leader
 Staff participation in tumor
boards/conferences
 Participation in
survivorship programs
 E-treatment pathways
 Complementary/integrative
cancer medicine program
 Patient Navigation
 E-genetic counseling
 SOP’s and quality
 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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Stage IV OR unresectable Stage III
Distant
metastatic
disease OR
UNresectable
Stage III
•
•
•
•
Biopsy of distant
disease
LDH
CT C/A/P & MRI
brain OR PET/CT
Path for BRAF
mutation
Melanoma
Edward S. Kim, MD
Chair, Solid Tumor Oncology
Treatment
“Monthly Section Meetings”
Patients should
be considered
for
multidisciplinary
discussion to
determine
potential for
surgical
resection
ECOG 1609
Adj Ipi vs IFN
Surgical
Resection
Resectable
Trial NEEDED
BRAF Not an IL-2
candidate
Without brain
metastases
Clinical Trial
Ipilimumab
Chemotherapy
PROCLAIM
Registry
Clinical Trial
Ipilimumab
BRAF inhibition
Chemotherapy
SELECT DFCI
Phase II BMS
BRAF +
IL-2
Candidate
Disseminated
(Unresectable)
See Followup Stage IV
NED
BRAF -
SRS +/- WBRT
BRAF +
Clinical trial or
Observation
With brain
metastases
Phase II Roche
MO25743
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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
 Treatment pathways/protocols
 Administrative team in place
 Phase I clinical trials unit(s) in
progress
 Phase II clinical trials – based
throughout CHS
 Academic leadership identified
 Cancer pharmacology lab team
 HOT lab
 Tumor Specific Teams
 Hem/Onc fellowship planning
 Educational courses
 Cancer Emergency Dept Network
 Leadership at Roper/St Francis
 Survivorship initiatives
 Navigator Academies 1 and 2
 Patient satisfaction/value/cost
 Single Tumor Registry
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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
 Rational selection of
treatment:
•
Outcomes should drive
•
Strong scientific rationale
•
Structured palliative care
 Measure and present robust
outcome data
 Reduce unnecessary costs
 Listen to the lay evaluations,
but structure them carefully
 Blue ocean/Red ocean
strategy
 Don’t listen to everyone
43