Treatment advances mean that, in many cases, cancer has become a chronic condition that must be monitored and managed during a lifespan not the end to a lifespan.
However, longer cancer management periods, along with the rising cost of treatments, also make it vital to address the financial challenges cancer creates for many patients.
For example, the American Society of Clinical Oncology has estimated that the cost of cancer care in the U.S. will rise from $125 billion in 2010 to $175 billion in 2020. That translates into a terrible burden on individual cancer patients and their families, and also impacts everyone through higher insurance premiums, employer health benefits costs, and taxes.
Dr. David Parda, chair of the Allegheny Health Network (AHN) Cancer Institute (see sidebar for bio), says that one obstacle to progress on both the medical and financial fronts is that cancer care has often been “fragmented.” In other words, different medical specialists, researchers, insurers, employers and others may become so focused on their specific expertise and responsibilities that they don't always see or act on improvements that depend on fighting cancer together.
On the medical side, Dr. Parda says the AHN Cancer Institute's multidisciplinary care coordination approach helps to prevent such fragmentation by organizing medical oncologists, radiation oncologists, surgeons, imaging experts, pathologists, and others around specific disease sites (e.g., lung, breast, colon, etc.) and patients. Specialized expertise is always tied back to the central goal of optimizing treatment outcomes for each patient.
Dr. Parda is helping to extend that mindset further as a leader of the Highmark Cancer Collaborative, which combines the medical expertise of AHN and the Johns Hopkins Kimmel Cancer Center with Highmark Inc.’s insurance and financial expertise.
The Highmark Cancer Collaborative aims to improve cancer care by identifying and promoting the best evidence-based treatments, removing administrative barriers and waste, and finding smart ways to control costs while ensuring the highest quality of care. Initiatives already underway include:
Don Bertschman (DB): What aspects of cancer care are we trying to improve in creating the Highmark Cancer Collaborative?
Dr. David Parda (DP): The progress we've made with cancer cure rates and cancer death rates over the last 50 years has really been a function of improving our multidisciplinary care coordination and treatment optimization approaches.
In other words, to get the best possible outcome for each individual cancer patient, you have to bring together all the experts for that disease site your imaging experts, pathology experts, surgery experts, radiation oncology experts, medical oncology experts. You bring everyone together to think about that patient's cancer and figure out the best way to coordinate the diagnostic and therapeutic approaches.
We've made a lot of progress on the delivery side of treating cancer, but the financial work in health care has been in its own silo, away from the point of patient care. So what we've done now is bring together our financial colleagues who have that expertise with the care providers.
The financing of cancer care is very complicated and very expensive, and it really is helpful to have financial experts working directly with care delivery experts with the shared goal of achieving better quality, access, experience and value on both the financial and delivery sides.
For the patient when you have cancer, of course the focus is on the clinical aspects of overcoming the cancer. But there are logistical and financial aspects that cancer patients and their families experience as well. As a matter of fact, up to about a third of cancer patients end up going bankrupt from their care. That's an unacceptable outcome that we can work together to prevent.
In this same room we’re talking in, we bring together a lot of these multidisciplinary groups. Everybody is really smart and strong-willed — we have surgeons, medical oncologists, radiation oncologists, imaging people, pathology people. We talk about these cases and everybody has strong opinions, but the only thing that sorts it out is what’s best for the patient, what’s best for the outcome. We’re not interested in your brilliant surgical capabilities or radiation capabilities or medical oncology capabilities, we’re interested in the patient’s outcome.
DB: Has collaborating with Highmark's financial experts given you new insights on how that side of the health care system works?
DP: Absolutely. It's a full-time job for any oncologist to keep up with cancer care the therapeutics, the biology, the individual patients and all the factors that we need to focus on. So we don't have expertise in that whole other world of how you finance health care.
There's a lot of expertise associated with the complexity of financing cancer care that needs to come together with our oncology expertise. You're not going to be able to take care of cancer patients and deliver these increasingly complex and expensive treatments if you don't have financial expertise and discipline.
The order of the day is to balance clinical, operational and financial activities to the patient's benefit.
DB: I like that focus on the benefit to the patient. Many aspects of the Highmark Cancer Collaborative seem to happen behind the scenes. Could you talk more about how the work impacts patients?
DP: Well, this isn't about convenience for oncologists or the Highmark insurance folks. It's all about what's best for the patient.
A cancer patient enters a health system that is complex and incredibly intimidating. Our job is to simplify that, and “unfragment” it. A cancer patient doesn't know anything about radiation oncology or medical oncology or surgical oncology as a division, or the differences between the radiology and pathology departments they just know they have cancer, and they want to know what they need to do and where they need to go. Our approach at AHN is to surround them with what they need, rather than force them to figure it out in a piecemeal way on their own.
The patient's experience will be improved to the extent that we unfragment it and make it less complex and intimidating. The more the individual cancer patient is informed and empowered, the better their outcomes will be.
The patient's overall health, well-being and immune status have a huge impact on their outcomes. It's not just the treatment that we deliver that results in the best possible cancer outcome. If we can unburden them from the incredible stress associated with cancer, including the logistical and financial stress, then cure rates will continue to go up.
Part of our expert cancer work is to work with the National Cancer Institute and our professional societies and other governmental agencies to come together and advance cancer care. The clinical trials process is the best example of that. Clinical trials have been the most important tool in advancing cancer care. The Phase 3 prospective, randomized clinical trial — where you’re comparing current best standard of care to next best standard of care. When we design these types of clinical trials, there are leading experts in the field that interact with the NCI and others in the health care industry, including pharmaceutical companies, medical device companies and so on, to put these studies together that help us incrementally advance care. We’ve just been through the reconstruction of the cancer cooperative groups, which have been streamlined from nine cancer cooperative groups down to four, and making changes to make the work more efficient, get the studies done faster and more effectively. The Allegheny Health Network Cancer Institute has been right in the middle of that, and we have many experts here who are leading cancer clinical trials experts. That’s an example of how you bring academic, government and industry together to advance cancer care.
DB: Could you walk me through how the AHN Cancer Institute's multidisciplinary approach helps simplify things? If I have bladder cancer, for example, what does AHN's approach mean for me?
DP: Because we organize our work at the disease site level, one benefit is that we have a bladder cancer group already in place. When you go for care at the AHN, we already have the surgeon, the radiology oncologist, the medical oncologist, the imaging and pathology folks all organized around bladder cancer. So you'll know who’s on the team treating you, and that every aspect of treating your bladder cancer is covered.
In some cases, all of the professionals are in the same physical location they may even meet with you at the same time. But even when that's not the case, we want to coordinate the care in as much of a real-time manner as possible. We want to minimize the cases where you go see one doctor, and then it's another week or two before you see the next doctor. The cancer is present and growing, so we need to surround the patient and get a game plan.
Again, it comes back to not wanting our patients to worry about the logistical aspects. We want them focused on their health and well-being and overcoming cancer. You don't want the health system to be something that adds to their burden.
DB: I know improving access to clinical studies is one goal here. Could you talk about the value of clinical studies, and what improvements are needed?
DP: A big focus of our collaborative efforts with Johns Hopkins is to improve access to cancer clinical trials and increase the availability of these trials to more patients.
Currently, only about 5 percent of adult cancer patients participate in cancer clinical trials. One reason is that there is a lot of operational and regulatory complexity to these trials and many community hospitals and programs without a lot of infrastructure are just not able to participate.
Part of what we're doing here is integrating our 24 community cancer programs with the centers at Allegheny General Hospital and West Penn Hospital, and with Johns Hopkins, so that we have a clinical trials network that is available to everybody, and so we can manage these efforts in a collaborative, centralized way.
On the insurance side, if we've gone through the vetting process to say this is a valuable clinical trial for our patients, we want the aspects of a trial that can be covered from an insurance standpoint to be covered. Highmark has done an excellent job in that respect.
DB: Is one of the challenges that there are too many “checks” on doctors being able to get patients into studies?
DP: A key thing for us is to better inform and empower cancer patients and their families, so that their care is not inappropriately reduced or restricted. We don't want operational or regulatory burden to limit their care in any way.
With that said, for a cancer patient to achieve the best possible outcome, you have to bring evidence-based discipline to the case. There are always new treatments, but you have to be careful about getting away from evidence-based standards that have been shown to cure a particular type of cancer. So you have to go in a disciplined, incremental way and say here is the current best standard of care for this individual patient, this treatment is proven to have the best possible cure rate. You start there, and then go to standard second line, third line, fourth line… and then you get to the more innovative treatments.
We all want new and innovative treatments to work, but before we apply them to patients, we have to make sure they're safe, effective and work better than the current standard of care. That's the sequence of clinical trials: a Phase 1 trial looks at safety; Phase 2 looks at effectiveness; in Phase 3, you compare what has been shown to be safe and effective to the current best standard of care.
Yeah, navigators are a key component to our moving care coordination forward in significant ways. We started a navigator program for the Allegheny Health Network Cancer Institute, and it’s really helped cancer patients by making it easier to understand and get to the different people and places that are part of their care. A navigator is a personal lifeline for that individual cancer patient. You know, even though a physician will spend a lot of time with a patient, there are still a lot of additional interactions that need to occur in order for the patient to be comfortable and understand all the aspects of their care. We’ve utilized nurse navigators, and there’s also been success with lay navigators in some programs. So that’s a big part of what we’ll be doing over the next few years is extending our navigation program for cancer patients. In fact, AHN and Highmark were just selected by the Centers for Medicare and Medicaid Services for their oncology care model pilot, and navigation is a key component of that pilot. They know that the way we need to move forward to optimize outcomes is to optimize care coordination, and navigators are a key component to that.
DB: What are you excited about in terms of future developments from the Highmark Cancer Collaborative? Or is that top secret?
DP: The order of the day is to have no secrets. The only way you advance cancer care and improve cure rates is to work in a transparent way where you share knowledge and expertise. That's why our Johns Hopkins collaboration has gone so well. These are incredible people who are totally focused on the patient and on advancing patient care. That's a very exciting and powerful way to work.
Care coordination will continue to improve we'll be able to do more and more for cancer patients outside the hospital. We don't want cancer patients to have to be admitted to the hospital at all unless it's medically necessary, so we'll bring more care to the community level, and have more care that can be delivered in the home.
We're going to keep expanding access to clinical trials, and to the rapidly advancing targeted agents and immunotherapy agents which are showing some significant and profound improvements in cancer outcomes.
DB: We did an interview last year w ith Leon Leach, PhD, an executive vice president at MD Anderson Cancer Center. One thing he brought up is that we're all in favor of new treatments, but our challenge is to figure out how to pay for them.
DP: It is a real challenge. Some of these new targeted agents and immune agents are very expensive to develop and can cost $10,000 or $20,000 a month. That’s part of the financial strain that cancer patients often have to endure. One thing about working collaboratively like this is that we can try to minimize that financial strain.
Sometimes the question is why does a new treatment cost so much? There have been articles in the Wall Street Journal and New York Times about how pharmaceutical companies set prices, and often it really is whatever they can get. They're not necessarily just covering their development costs. So there is interaction that can occur with Highmark and AHN and pharmaceutical companies to optimize the care and manage the costs.
That's also part of the value of the decision support software we're using as part of the Highmark Cancer Collaborative, Clear Value Plus (see sidebar). As oncologists, we want our patients to have access to every possible treatment that can advance their care, but we need to have more understanding of the financial impact of treatments on our patients as well.
DB: What about your personal connection to the Highmark Cancer Collaborative? What motivates you to put your time into helping to create and lead a program like this?
DP: We're completely focused on optimizing outcomes for cancer patients, so that's the motivation. If we really want to optimize outcomes for patients, then we need to share knowledge and expertise and work in a collaborative and collegial way across many disciplines. That's the complete motivation. And, as we focus on the patients and their outcomes, we'll find that a lot of processes can be improved in dramatic ways.
A big part of the success of Highmark as an insurance company is to get closer to the point of patient care and say what’s best for the patient. Of course we need to be financially disciplined about how we do it. I’ve been very encouraged that they are closer to the point of patient care than they’ve ever been. It’s exciting to get them there — again, this is something we all encounter personally. A lot of insurance folks and financial folks develop cancer and come into our health system, and they want it to be better too. It’s not about gamesmanship, it’s about optimizing the delivery and financial aspects. There’s plenty of work to be done without a lot of smoke and mirrors.