The 39th Annual National Meeting of the Association of Community Cancer Centers (ACCC) was held in Washington, DC, in March. With a focus on business, economics, and policy, the program included the inauguration of a new ACCC President (see page 102), a keynote speech on the future of health care, and panels on the impact of a divided Congress on health care and the challenges involved in defining quality care.
Forecasting the Future of Health Care
What is likely to get in the way of providing quality cancer care, and what can smooth out the bumps in the road to cost-effectiveness? These were two major questions that Jeffrey C. Bauer, PhD, addressed in his keynote speech. Dr. Bauer is an independent health futurist and medical economist—and, as he declared at the outset, a strong critic of the Affordable Care Act. “Political reforms are not an effective way to fix how health care is provided,” he commented.
“Health care will change more in this decade than it has in the past 50 years, but for that change to be positive, it is critical that we analyze information about alternative actions,” he said. He described trends that will shape the future:
A revolution in medical science is shifting providers’ core function from acute care to chronic disease management. The one-size-fits-all clinical paradigm is being replaced by personal predictive medicine, and diseases long seen as single entities are now recognized as different conditions with a range of biologic interactions. Care will be more cost-effective as therapies are matched to individual patients.
New information and communication technologies are transforming business models and production processes. Robust IT networks will be the necessary foundation of good medical practice, and integrated record systems will be essential for cost-effective cancer care.
The end of growth in health-care spending is restructuring provider-patient relationships. Governments and employers are reaching the limits of their ability and willingness to spend more on health care, and the market will shift from fee-for-service reimbursement (quantity) to value-based payment (quality). Demand will change significantly as patients are expected to pay an increasing share of the costs.
Problems with government-driven reform are compelling providers to develop successful futures on their own, in spite of state or federal mandates. The rushed legislative process produced a flawed Affordable Care Act that is unlikely to be improved by amendments. Legal challenges will serve only to create an uncertain environment for conforming to the law.
Dr. Bauer forecasted that by 2015, 30% of health-care delivery systems will not be doing business as they are today (or not doing business at all), 45% will still be in business (but precariously), and 25% will be in business and thriving as a result of making needed changes.
He suggested a number of ways to provide quality cancer care: Develop integrated and personalized care packages; use information and communication systems to manage services; offer services as inexpensively as possible; build long-term, multi-stakeholder partnerships with other providers, payers, purchasers, and patients; and reinvent cancer care independently of government health reform.
What a Divided Congress Means for Health Care
Over the past several years, Congress has been gridlocked over almost everything, and amid the squabbles and outright fights, community oncology has been largely ignored. Matthew Farber, ACCC Director of Provider Economics and Public Policy, and panelists explored the likelihood of compromise occurring any time soon.
He opened the discussion by noting that the many short-term fixes in recent years will not work, especially because Congressional attention is focused on sequestration—and will be for the foreseeable future.
Sydney K. Abbott, JD, ACCC Manager of Provider Economics and Public Policy, said that regardless of Congressional attention elsewhere, the association must keep up its educational and lobbying efforts. “Almost everyone is unhappy with Congress. People are angry and know that change is necessary, but they don’t see where it needs to be made. So it is our job to let lawmakers know what has to be done for patients with cancer.”
Cara Tenenbaum, Esq, Vice President for Policy and External Affairs, Ovarian Cancer National Alliance, advocates for appropriations and regulations. “All senators and representatives have a lot on their plates. They want to help cancer patients but they look to us as advocates for advice on how to do so,” she said.
“It’s up to ACCC members,” said Ms. Abbott. “Congress is a reactionary organization and will address the issues its members see as important. Therefore, it’s up to us to tell them what we want.”
Quality Cancer Care
Should quality cancer care be defined by providers? By payers? By patients? In oncology, where not all treatments are intended to be curative, is an industry-wide definition of quality care possible—or even appropriate?
The panelists couldn’t answer the question, but moderator Clifford Goodman, PhD, Senior Vice President, The Lewin Group, pushed hard to stimulate a discussion. He began by noting, “There is a broadening realization that defining high-quality cancer care depends on many perspectives, and the definition will vary across them. Survival is no longer the sole element in determining quality of care.”
Randall A. Oyer, MD, Cancer Program Director, Lancaster (Pennsylvania) General Hospital, said that for care to be valuable, expenditures must be allocated and used wisely. “Consumers have expectations that may not be possible to meet,” he said, adding, “We also have to take into consideration the change in management from acuity to chronicity.”
Linda House, RN, Executive Vice President of External Affairs, Cancer Support Community, noted that cancer is most prevalent in people over age 65, who are among the most empowered. “A lot of them believe they know what cancer treatment involves, but they don’t know what it means—and neither do we. So before we can assess whether people are receiving good care, we must first identify what it is.”
John Fox, MD, Senior Medical Director, Priority Health, noted that patients are concerned with much more than 5-year survival, and in fact, overall survival is not the only appropriate measure of quality. Patients want and need other elements of care, but we’re still not sure what they are. In other words, we need to know what really bothers people about having cancer.
Reimbursement Models and Outcomes Research
Payers are affecting treatment decisions by using various reimbursement models that incorporate quality (such as reducing hospital admissions) in decision-making. The pathways approach is one such model.
The panelists acknowledged that use of pathways as a way to make decisions about treatment is increasing, but there was no agreement about whether this is a good thing. Do pathways improve quality or act as a barrier to good care? What parameters should affect their use, and should they be used at all? Are they indeed a good quality indicator? And if so, should the goal be total compliance with recommended pathways?
Dr. Goodman noted that outcomes research is likely to strengthen the role of patients in decision-making. “Most people are interested in dimensions beyond survival, such as side effects and quality of life.”
The panelists agreed with Dr. Jimmie Holland that levels of distress should be assessed and screening tools developed (see sidebar). They also agreed that when patients play a role in decision-making, they are more likely to be satisfied with the treatment they receive, and thus view their care as good. However, said Ms. House, health literacy needs improvement so patients can benefit more, objectively and psychologically, from whatever decisions they make.
Dr. Goodman asked a final question, the most difficult one: How will we know when we’re delivering high-quality care? At Dr. Goodman’s prodding, the panel arrived at a tentative collective response: Quality care happens when patients receive the treatment they want. ■
Jimmie C. Holland, MD, Wayne E. Chapman Chair in Psychiatric Oncology, Memorial Sloan-Kettering Cancer Center, received ACCC’s Annual Achievement Award for excellence in advocacy, dedication, and commitment to the care and treatment of patients with cancer.
In her acceptance speech, Dr. Holland...