CCAIESSENTIAL TO PROGRESS AGAINST

CANCER

A National Problem:

• Rising health care costs are unsustainable• Survival of the U.S. population isn’t any better

than countries with much smaller expenditures on health care.

• Cancer patients sustain greater out of pocket expenses, and more bankruptcies than any other chronic disease.

The high cost of cancer in Idaho

• Private insurance spends more on cancer in Idaho than any other disease, and proportionally more than anywhere in the U.S.

• Can we seize the opportunity to decrease costs while keeping our death rate low?

National Vital Statistics Reports, Vol. 61, No. 6, October 10, 2012

What are the ways to improve outcomes in

cancer care?• Increase value of screening and treatment

• Increase value of research

• Increase health through education

• Increase access to care

• Increase participation in all of the above

What is the most efficient path to improving health?

• Two paths, two different outcomes: England NHS, vs Japan Universal Health Care.

Lancet 2011; 378: 1094–105Lancet 2011; 378: 1174–82

Healthy Care: Complex and Adaptive

Value in Health Care:Lessons from Complex Adaptive

System Science

• Rule 1: The stakeholders agree on a set of mutual, measurable goals for the system.

• Rule 4: Stakeholder incentives, imperatives, and sanctions are aligned with the agreed-on health system goals.

• Rule 5: Leaders of all stakeholders endorse, promote, and honor the agreed-on health system goals.

Thomas E. Kottke Prev Chronic Dis. 2012; 9: E49.

Maximizing the Value of Cancer Care

•Value = Benefit Cost

Defining the Value of Cancer Prevention,Screening, or Treatment

• Survival• Quality-adjusted survival (QUALY)• Quality of life

– Symptoms of cancer– Side effects of treatment

Cost

Toward Patient-Centered Drug Development in OncologyEthan Basch, M.D. N Engl J Med 2013; 369:397-400

What are the ways to improve outcomes in

cancer care?• Increase value of screening and treatment

• Increase value of research

• Increase health through education

• Increase access to care

• Increase participation in all of the above

Defining the Value of Cancer Trials

• Transparency• Stakeholder involvement• Owner of Data

Cost

Federal Approach to Cancer Research

• Veterans Administration: Started the first multi-institution trials - initially in tuberculosis

• With this successful model, cancer research cooperative groups formed starting in 1955

• Co-ops have been successful, and on a shoestring—dozens if not hundreds of trials funded for the same cost as a single randomized pharma trial

ASCOPost 5:Issue 5, p 58-59

Threats to federal research

• There has been a 60% reduction in accruals across the country in cooperative studies, due to drop in funding and recent merging of cooperative groups.

• There are more funding cuts planned in the near future

ASCOPost 5:Issue 5, p 58-59

What are the ways to improve outcomes in

cancer care?• Increase value of screening and treatment

• Increase value of research

• Increase health through education

• Increase access to care

• Increase participation in all of the above

Education is likely important to early health

• Intensive education starting at a very early age may increase cognition, and educational attainment, but may also independently improve health and healthy behaviors. This has been hypothesized to be extremely cost effective.

• We need larger studies to confirm these findings, and explore many questions arising from the early studies

Am Jrnl Public Health 101: p 512-516, 2011

What are the ways to improve outcomes in

cancer care?• Increase value of screening and treatment

• Increase value of research

• Increase health through education

• Increase access to care

• Increase participation in all of the above

Increased access

• Oregon health insurance experiment showed improved patient reported outcomes. It also showed increased utilization of primary care, preventive care, hospitalizations and emergency rooms

Q J Econ 2012; 127:1057-106Science 2014; 343:263

The Value of Preventing Disparities in Delivery

• Those likely to find cost a barrier to care are minorities

• Minorities, although they have a lower rate of breast cancer, are affected at a younger age

• Curing cancer at a younger age has greater value

Olufunmilayo Olopade, Examining the role Genetics Plays in Breast Cancer Onset. ASCOPost July 25, 2013.

What is the best way to address the issue of disparities in Idaho?

• Will the Oregon Health Experiment tell us if outcomes in cancer will be better with expanded Medicaid coverage?

• Or will other barriers be larger in Idaho?

N Engl J Med 2013;368:1713-22.Science 2014; 343: 263-268 Am J Manag Care. 2012;18(5 Spec No. 2):SP65-SP70)Social Science & Medicine 2008; 67, Issue 10, 1604–1611http://nihrecord.od.nih.gov/newsletters/2011/11_11_2011/story4.htm

The value of eliminating disparities in care

• $77 billion annually in direct costs nationwide.

http://www.jointcenter.org/hpi/sites/all/files/Burden_Of_Health_FINAL_0.pdf

What are the ways to improve outcomes in

cancer care?• Increase value of screening and treatment

• Increase value of research

• Increase health through education

• Increase access to care

• Increase participation in all of the above