Regular readers of the MNCC will know that we rarely write about “news” in the world of cancer care, but today I am making a bit of an exception.
An entry published over the weekend in the “Opinionator” blog of the New York Times promoting a “plan to fix cancer care” caught my eye, and I thought after reading the column that the topics covered therein would provide plenty of fodder for our discussion here tonight. It seems especially appropriate given the conversation we had last week at the MNCC.
I’ll summarize the points made by the author, Ezekiel J. Emanuel, after providing a few details of his biography. Emanuel is an MD who has practiced in oncology; he is also a Ph.D. bioethicist and a fellow at the Hastings Center. Currently he holds a position at the NIH and still serves (from what I can tell) as a special adviser to the Director of the OMB on Health Policy. Interestingly, though I’m not sure it pertains to this particular discussion, he is Rahm Emanuel’s oldest brother. Emanuel also had over 20 medical reviewers of this post, including Otis W. Brawley of the American Cancer Society among the other MDs and PhDs listed.
Emanuel opens by asserting that the cost of providing treatment to people with cancer is unsustainable: currently, 0.5 of the U.S. population is under treatment for cancer, for a share of 5% (and growing) of total U. S. health care expenditures in doing so. Then he quickly lists the five major components of his plan with brief descriptions of each.
Number one is shifting from a fee-for-service model to a bundled payment model—that is, setting a flat fee for certain cancers, presumably depending on their stages and treatments. The second is to require insurers to document and report back to the physicians on the costs of the treatments they prescribe, in large part to allow doctors to compare costs and effectiveness. “Armed with better data,” he says, “physicians can learn how to improve care at lower cost.”
“Third,” he continues, “any change in payment methods must be accompanied by rigorous quality monitoring to ensure that there is neither under- nor over-utilization of care.”
The fourth component is to move toward more of a “high touch” model of health care because it can help minimize unnecessary treatment expenditures. This is was not a familiar term to me, but I gather that it is intended to contrast with “high tech,” and here he uses it to recommend more routine interactions between medical providers and patients (though his examples strike me as somewhat oddly chosen).
Fifth and last, he says we need “better incentives for research….[because once] interventions are paid for, the incentive for research disappears.”
He concludes by recommending that
The secretary of health and human services should organize a working group representing Medicare, private insurers, oncologists, quality experts and patients to figure out how to develop these proposals — with no increase in costs — and start implementing them by the end of 2015.It would probably aid our mutual understanding if you would be so kind as to read the original post, which is quite short, as well as some of the comments that follow it, many of which are well-argued and instructive. I’ll lay out the questions I’d like us to consider after the jump.
Monday Night Cancer Club is a Daily Kos group focused on dealing with cancer, primarily for cancer survivors and caregivers, though clinicians, researchers, and others with a special interest are also welcome. Volunteer diarists post Monday evenings between 7-8 PM ET on topics related to living with cancer, which is very broadly defined to include physical, spiritual, emotional and cognitive aspects. Mindful of the controversies endemic to cancer prevention and treatment, we ask that both diarists and commenters keep an open mind regarding strategies for surviving cancer, whether based in traditional, Eastern, Western, allopathic or other medical practices. This is a club no one wants to join, in truth, and compassion will help us make it through the challenge together.
To discuss a statement like this requires some unpacking of the overall argument. Hence my first question to you would be this: Do you agree with him that the expenditures on treatment for cancer in the U.S. are 1) disproportionately high and 2) not necessarily indicative of good and effective care? On what do you base your own opinion?
Next I would ask us to consider whether that’s indeed the biggest problem about cancer care in the U.S.—namely, an excess of expenditures for little obvious gain in health or prolonged life—or whether there is another set of questions that might take precedence even over this one. I know that meta isn’t everyone’s cup of tea, but here it seems worthwhile to take a sip of it all the same. If the problem isn’t properly framed and understood, then the purported solutions will be even farther away from producing a worthwhile change in the underlying situation.
Then, of course, we can take up each of his proposed “solutions” in relation to the problem as he understands it. Or not! If we think that there are in fact other aspects to be considered that aren’t part of this schema at all.
These are some of my very preliminary responses to each. Some of these are bound to be contentious, which is not necessarily a bad thing. I admit to being a novice in the health care funding field and hope to learn more, and quickly.
1. Fee-for-service might lead to some pernicious results, but does a bundled payment approach work better? Weren’t HMOs discredited in part because the providers had a perverse disincentive to pay less attention to their sickest patients? How would such a system work if we were to be able to move (as I fervently hope) to a single-payer or Medicare-for-all model—easily compatible or a difficult fit?
2. Pushing for cost reports and comparisons reminds me of that famous Atul Gawande essay in the New Yorker a couple of years back, “The Cost Conundrum,” Gawande argued convincingly that there was no necessary relationship between the amount of money spent on patients’ care and their overall health—that often better results could be obtained with lower-cost and more labor-intensive (read: more medically coordinated and interactive) care. Great essay, even better insight. But who is going to monitor those costs? And to what end, really? Just to reduce them, or to see that better treatment models are implemented?
This also addresses Emanuel’s point #3.
4. “High touch” vs. “high tech.” Since this wasn’t a familiar concept to me, I went looking, and I found an interesting example of Emanuel’s position on this point from a few years ago. In coverage of a speech he gave to a medical group management meeting in 2009, Emanuel was quoted as saying that “High-touch…means more patient contacts, more proactive monitoring of patients, more data-driven care, more access to physician offices and more coordinated care.” OK, that might be promising, and certainly I can attest to wanting more information (which at this point is probably for me the major outcome from having more interaction with my medical providers). But who pays for these personnel? How will they be trained and deployed effectively? Who will have their interests at heart, rather than supporting the profit-making models that do well by the administrators but not so well by the patients? And again, who minds the shop to see how well this model pans out?
5. The need for “better incentives for research” seems very obvious, and yet again the design and implementation of these improvements seem mysterious. I do not know the dynamics of research funding well enough to comment intelligently, but I also find it frustrating (as did several of you in last week’s comments) that the pace and scope of cancer research still seem so limited.
What do you think of his concluding call to create a national working group to discuss these proposals and come up with a plan to address them? Who do you think should be in this group? Would you want to be on it? What would you want to make sure they address?