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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
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Poverty
•
Educated
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Large state
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Fewer indigent
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Poor access
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High density academics
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Poor education
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High density proximate hospitals
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African American cultural issues
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Dartmouth engineers of healthcare
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Targeting of advertisers
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Work conditions
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Work conditions
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Liberal state
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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
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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
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Identification via Tumor Registry and Physicians
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Structured algorithms
•
Engagement of medical staff of system hospitals & practices
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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)
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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
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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
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