Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, FAAAS
THERE IS little doubt that the U.S. health-care system is under assault from many directions.1 It is clear that the costs of health management are no longer sustainable, and the United States has one of the highest per capita health costs among the 36 member nations of the Organisation for Economic Co-operation and Development. Government has attempted to improve the situation, and that has proven to be a highly unsuccessful approach in those nations with nationalized health care.
Shift to ‘Curve 2’
AS PHYSICIANS, we have our own problems: dysfunction within our profession that includes competition among practitioners and persisting lack of self-regulation of volume-driven and per-service reimbursed care that often causes us to use treatments that make little sense and/or are poorly supported by objective evidence. We have never been very effective in policing our value-based performance, nor in advocating for ourselves.
“[Physicians] have never been very effective in policing our value-based performance, nor in advocating for ourselves.”— Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, FAAAS
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In oncology, ASCO and the European Society for Medical Oncology have done yeoman’s labor in setting better standards of management and quality assessment. Unfortunately, studies have shown that many initiatives have not been actively adopted by our constituents. A perfect example is the continued refusal to follow the “Choosing Wisely” dicta,2,3 with some oncologists continuing to employ practices that create remuneration without obvious benefit to their patients.4
Somewhere along the line, those who govern health policy came up with the concept that, in a health environment where the focus is fee-for-service, it might make more sense to emphasize value—most simply defined as outcome divided by cost—and thus shift to a “curve 2” approach, in which costs would be reduced by a greater emphasis on getting “more bang for the buck.”
In the traditional model, health-care reimbursement has been focused on a volume-based “first curve,” characterized by fee-for-service, in which high quality is not specifically rewarded. Curve 1 typically involves no shared financial risk, a lack of attention to investment in informatics, the impediment of hospital-clinician collaboration by the regulatory environment, and an emphasis on stand-alone health-care systems.
Economic futurist Ian Morrison proposed the shift to curve 2. This model is characterized in the health-care context by a value-based approach, emphasizing rewards for population value and improved quality, partnerships with shared risk, increased patient acuity, coordination of care encouraged by realigned incentives, and greater use of artificial intelligence and informatics.
Hospital Practice Perspective
THE AMERICAN Hospital Association, viewing the need for change purely from the view of hospital practice, has adapted curve 2 principles for its leaders by enumerating the following focal points5:
A quick glance shows remarkable congruence with the principles of health-care policy reform enunciated by Porter and Teisberg,1 and there is nothing wrong with these fundamental concepts. However, there are some crippling problems that few of our health leaders and those who lead health policy for government agencies seem to have formulated into their constructs.
Although physicians and their professional societies have begun to do their part (with variable enthusiasm and efficacy, as outlined above), the other key players really have not done so, notwithstanding a great deal of lip service. It seems patently clear, despite their public protestations and rhetoric, that most payers appear to have no interest in any type of truly cooperative venture. Some insurance companies are purchasing physician practices so that they can control the agenda and define “quality” in terms that ultimately allow them to continue to pay annual eight-figure bonuses to their top executives.
The hospital concept of population management is often focused on how to move a greater proportion of the population into their intake systems and leveraging a new principle of management—that “big is better,” irrespective of the potential for dilution of quality with increase in size.
GOVERNMENT CONTINUES to be overwhelmed by beltway partisan bickering, lack of clear policy, lack of vision or solutions about how to pay for health care, and reluctance to acknowledge the limitations in their ability to provide the outstanding health care routinely promised by politicians on the hustings. Furthermore, and importantly, our government is completely unable to deal with the onslaught of the lobbyists with protected vested interests—for example, the electronic medical record industry, for which there is no regulation, leading to poor quality, high prices, and a lack of solutions to excessive time expenditure by clinical staff for the most routine clinical tasks. (Who has managed to enter a complex chemotherapy order in most systems in less than 30 minutes?)
“[O]ur government is completely unable to deal with the onslaught of the lobbyists with protected vested interests….”— Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, FAAAS
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Similarly, lobbyists effectively protect many domains of the pharmaceutical industry. Resulting problems include the pricing of chimeric antigen receptor T-cell treatment unconnected to research and development costs, a lack of effective solutions to the frequent unavailability of crucial generic drugs, and the absence of protection against importation of less expensive drugs from abroad).
In addition, the prevailing view of the current administration, which increasingly ignores the health care of the uninsured and underinsured, will contribute to worsening outcomes and burgeoning downstream expenses that simply cannot be managed by the physicians of our nation in isolation. A note to our politicians: it is not rocket science to understand that the delayed management of early disease among the poorest and most vulnerable members of our population will culminate in manifold increases in national costs when we are faced with managing those same disorders at advanced stages.
Another evolving crisis is the ridiculous and impractical disconnect between ever-increasing government requirements for documentation and the Joint Commission’s focus on power and control vs the reality of time and expense to achieve the many unnecessary goals. In turn, this leads to an increased level of burn
out and early departures among many of our best physicians and nurses when they would normally be at the peak of their experience and career paths.
Addressing the Issues
LET ME be very clear: I completely applaud the need for improved standards and values, better communication, relevant oversight of quality, transparency of measuring and declaring outcomes, and even the importance of redefining work-life balance. However, many of the documentation, access, and “safety” requirements of those who oversee and regulate health care are completely unconnected to good clinical practice or patient welfare. In many cases, they actually reflect the governmental emphasis on power, control, and use of financial penalty as a weapon to achieve control wherever possible.
“It is time for health care to be characterized by increased transparency and a realistic approach to setting healthcare goals….”— Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, FAAAS
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This situation really doesn’t require complex solutions. We need dedicated bipartisan government involvement, with engagement of key stakeholders in health care, and regulatory separation of lobbyists from the table. It is time for health care to be characterized by increased transparency and a realistic approach to setting health-care goals, including the recognition that we simply cannot continue to provide every new treatment for every patient irrespective of context and realistic outcome expectations.
Our approach at the Levine Cancer Institute, as described by Ibrahim and Dimick in their review of future approaches to health care,6 addresses many of these issues. We have developed a distributed network of oncologists at more than 20 sites, implemented and leveraged evidence-based electronic management pathways that include our trials, and adopted a centralized institutional review board and extensive nurse navigation. We have established active integration of the pharmacy and therapeutics committee into careful consideration and rationalization (not rationing) of the value of the various treatments; active outreach; and education, prevention, and disparities programs. We have leveraged pharmaceutical savings associated with clinical trials, the use of a molecular tumor board to refine and focus the use of targeted therapies, and computer and electronically linked system-wide tumor boards and conferences to provide academic discussion of all complex or challenging cases and/or review of routine cases via consent agendas.
Whether this is the correct approach will become clear as we measure outcomes over time. What is not in doubt is that new strategies of care—focused on the value proposition—will be essential. But the potential for active and collaborative help from government, regulators, and the industries associated with health care remains less well defined. ■
Dr. Raghavan is President, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. Raghavan is an unpaid consultant/advisor for Caris Life Sciences and a consultant/advisor for Gerson Lehrman Group.
1. Porter ME, Teisberg EO: Redefining Health Care: Creating Value-Based Competition on Results. Boston, Harvard Business School Press, 2006.
2. Schnipper LE, Smith TJ, Raghavan D, et al: American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. J Clin Oncol 30:1715-1724, 2012.
3. Schnipper LE, Lyman GH, Blayney DW, et al: American Society of Clinical Oncology 2013 top five list in oncology. J Clin Oncol 31:4362-4370, 2013.
4. Rocque G, Blayney DW, Jahanzeb M, et al: Choosing wisely in oncology: Are we ready for value-based care? J Oncol Pract 13:e935-e943, 2017.
5. Health Research and Educational Trust: The second curve of population health. American Hospital Association. March 2014. Available at www.hpoe.org/pophealthsecondcurve. Accessed January 8, 2019.
6. Ibrahim AM, Dimick JB: Redesigning the delivery of specialty care within newly formed hospital networks. NEJM Catalyst; March 30, 2017. Available at https://catalyst.nejm. org/redesigning-specialty-care-delivery. Accessed January 8, 2019.