The Importance of a Medical Home for Cancer Patients

And How We Might Get There

Richard C. Wender, MD

Alumni Professor and ChairDepartment of Family & Community Medicine

Thomas Jefferson University

Immediate Past President, American Cancer Society

The American Cancer Society: 2015 Goals

In May 2002, the ACS approved a challenge goal for the nation to achieve a 50% reduction in age-adjusted cancer mortality by 2015 from the 1990 peak

Progress Is Being Made

• A midpoint report revealed approximately a 1% annual decline in cancer mortality from 1990-2002

• 315,000 cancer deaths were prevented

• On current pace, 1.9 million cancer deaths will be prevented by 2015

But We Have A Long Way To Go

• We’re on a trend to achieve about half of the 2015 goal

• Accelerating progress to meet the goal will prevent an additional 2.3 million deaths

Byers, T et.al. Cancer 2006; 107

For The Most Part,

We Understand

The Root Causes

Of Our Successes

Copyright ©2007 American Cancer Society

From Jemal, A. et al. CA Cancer J Clin 2007;57:43-66.

Age Adjusted Mortality For Men – 1990-2003

Copyright ©2007 American Cancer Society

From Jemal, A. et al. CA Cancer J Clin 2007;57:43-66.

Age Adjusted Mortality For Women - 1990-2003

Key Interventions That Are Working or Have Worked

1. Reduction in smoking – particularly in men

2. Improved breast cancer early detection (mammography). And treatment of early disease

3. Colon cancer reduction in incidence due to polyp removal and, possibly, estrogen, NSAIDS, and folate in women

Key Interventions That Are Working or Have Worked

4. Prostate cancer detection and treatment

5. Improved therapy for most cancers, particularly childhood and hematologic malignancies

But we asked:

What will it take to get all the way

to our goals to ultimately win the

cancer fight?

What Will It Take To Achieve 2015 Goals And Beyond?

• A cancer healthcare agenda driven by public health considerations

• A public health analysis of research investment

• An emphasis on primary care

• Expanded access to primary and cancer care services

• Institution of systems of care to replace the clinician as the sole pilot of care

• Payment mechanisms to support these systems

We must follow two roads to healthcare reform:

Improving coverage

Improving health care delivery

Any viable solution must control cost

Addressing Coverage –

A critical step to winning the cancer war

0%

10%

20%

30%

40%

50%

1 2 3 4

Stage at diagnosis among all breast cancer patients diagnosed in 1990-2000 and reported to the NCDB

Private

Uninsured

Medicaid

Impact of Insurance on Stage at Diagnosis for Breast Cancer

Odds of More Advanced Stage at Diagnosis, Colorectal Cancer, NCDB, 1998-2004

Insurance Stage II vs. IStage III or IV vs.

I Private 1.0 (Ref.) 1.0 (Ref.)

Uninsured 1.9* 2.0*

Medicaid 1.4* 1.6*

Medicare Age 65+ 1.0 1.0

Race Non-Hispanic White 1.0 (Ref.) 1.0 (Ref.)

Non-Hispanic Black 1.1* 1.3*

Hispanic 1.1* 1.1**Odds ratio is significant at the 95% confidence level.Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of diagnosis, and facility type..Source: Halpern et al, 2007 (manuscript in preparation)

6%

7%

7%

9%

10%

22%

6%

15%

35%

41%

34%

30%

46%

3%

Everuninsuredduringillness

Alwaysinsuredduringillness

Consequences of Financial Costs of Cancer by Insurance Status

Declared bankruptcy

Borrowed money from relatives

Contacted by a collection agency

Unable to pay for basic necessities like food, heat, or housing

Sought the aid of charity or public assistance

Borrowed money/got a loan/another mortgage

Used up all or most of savings

Percent who say each of the following happened to them/their family member as a result of the financial cost of dealing with cancer…

Source: USA Today/Kaiser Family Foundation/Harvard School of Public Health Cancer Survey (conducted August 1 – September 14, 2006)

Improving Health Care Delivery Infrastructure:

Increasing Access To The Primary Care Medical Home

An Emphasis on Primary Care Services

Why Is Primary Care Important?

Starfield 09/0404-134

Better health outcomes

Lower costs

Greater equity in health

Starfield 09/04PC 2945

Higher Primary Care Supply is Associated With:

• Increased likelihood of early detection of:

• Breast Cancer

• Cervix Cancer

• Melanoma

• Colon cancer

Starfield 03/06IC 3384

An orientation to primary care reduces sociodemographic and socioeconomic disparities (inequities)

• in access to health services

• in population health

Starfield 03/06IC 3383

Medical home is similar to global warming. The evidence is clear. It’s just a matter of whether we have the will to do something about it

What is the road to health care reform that includes support for the primary care medical home?

Focusing On Reform Through The Cancer Lens - A Smart Strategy

7%

15%

32%

40%

Reducing spending on governmentprograms like Medicare and Medicaid

Improving the quality of care andaddressing medical errors

Expanding health insurance coverage forthe uninsured

Reducing the cost of health care andhealth insurance

Health care top domestic issue

Health care remains the top domestic issue for

Americans in the upcoming presidential election.

Source: Kaiser Family Foundation, Kaiser Health Tracking Poll: Election 2008, October 2007.

Values and barriers

• Health care has become a core value.

• The concept of “quality affordable health care" is more appealing than “universal coverage."

Source: Lake Research Partners, November 2006.

Voters are insured and worry about health care costs

• Health care is salient to voters.

• Americans are worried about the rising costs of health care.

• Feel they are getting less for more.

Sources: Lake Research Partners, November 2006; Kaiser Family Foundation, Health Security Watch, October 2007.

Costs of covering uninsured

• Majority of the uninsured (80%) are working families.

• Feel “sliding scale” works

• While voters agree everyone should have access to health care, they don’t want to pay for the “undeserving.”

Source: Lake Research Partners, November 2006.

Voters feelings about private insurers and government’s role

• Voters often support reform proposals in principle —but pull away when it may adversely affect them personally.

• Insurance and drug companies are making excessive profits.

• Government has a role as a watchdog.

Source: Lake Research Partners, November 2006.

Preventive care as stepping stone

• Seen as “common sense” investment.

• Guaranteeing access to preventive care is a clear role for rules and government.

• Preventive care is potential escalator.

• Prevention seen as encouraging personal responsibility.

Source: Lake Research Partners, November 2006.

Most Important Diseases or Health Conditions the Government Should Address?

11%

16%

21%

41%

51%

Diabetes

Heart disease

Avian flu

HIV/AIDS

Cancer

Harvard School of Public Health and the Robert Wood Johnson Foundation, Americans’ Views of Public Health, April 2006.

Cancer Screening for all Americans most popular among proposals

0% 20% 40% 60% 80%

Health Care Bill ofRights

GuaranteedAffordable Plan

HealthyGeneration

Cancer Screening

10 8 and 9

Source: Lake Research Partners, November 2006.

74%

68%

66%

65%

Voters want doctor-patient relationship safeguarded

0% 20% 40% 60% 80% 100%

Insurance companies and HMOs should neverbe allowed to come between you and yourdoctor when it comes to decisions about you

and your health.

The government should never be allowed tocome between you and your doctor when it

comes to decisions about you and your health.

Strongly agree Not strongly agree

Source: Lake Research Partners, November 2006.

90%

91%

When talking about health care…

Words to Use • Quality affordable health care• American health care• Sliding scale• Prevention• Smart investments; investing in

the future• Choice• Rules• Guaranteed• Giving people control; peace of

mind • Standard package; affordable

health plans• Public/private partnership• Government

enforcement/watchdog

Words to Avoid• Universal coverage• Medicare for All; A system like

Social Security; Canadian Style Health Care

• Free• Wellness• Inexpensive • Competition• Regulations• Required• Government health care for all

• Basic health care • Public health care• Government health

Source: Lake Research Partners, November 2006.

Cost Considerations May Block National Reform Efforts

Constraints

• The national debt

• The federal deficit

• Expiration of Bush tax cuts in 2010

• Medicare growth

• Medicaid growth

Nation Debt: $9.0584 Trillion (October, 2007)

• Growing by $1.42 billion/day

• $29,866 per person

• $58,954 per worker

• Median household income: $48,206 (2006) (average of 2.6 persons per household)

• Mean household income: $60,528

The Federal Budget Deficit

• About $158 billion for 2007 (FY ended 9/30/07)

• OMB and CBO predict deficit through 2012 (and unofficially much longer, based on current tax and entitlement policy)

• Last federal surplus was 1998-2001

Bush Tax Cuts

• All the tax cuts enacted under President Bush expire on Dec. 31, 2010

• If allowed to expire, there would be a small surplus for 2012-2017, but then deficits begin again because of entitlement growth

• Extending all of the Bush tax cuts 2010-2014 would cost an additional $1.2 trillion, and it grows thereafter.

Entitlement Growth

Implications

• The next president and Congress are going to be engaged in an intense debate about the budget and taxes.

• The budget debate will inevitably raise the issue of changing entitlements.

• There will be very little “free” money for health care reform, at least until the tax extension issues are resolved.

So What Should We Be Doing?

Health Care Reform Will Require New Collaborations . . . And Some Strange Bedfellows

• The Massachusetts plan was designed by putting the insurance companies, bastions of capitalism, government, and die-hard liberal reformers in the same room…and refusing to give up.

Will National Reform Occur Soon?

• National reform will demand:

–A president willing to put his or her reputation on the line

–A congressional majority of the same party

–Broad public demand

–Confidence that it can be done

States Will Lead

• States have variable levels of uninsurance

• Variable economic resources

• Variable political environments

States Need To Lead

• We need to draw the roadmap to access – states can be the experimenters

• When 20 states make meaningful change, national change will look more feasible

Enlist The Cancer Community As A Supporter Of Medical Home . . . . And Medical Home Advocates Should Embrace A Cancer Focus

The ACS Vision

By 2015, everyone will have timely access to the full range of affordable evidence-based healthcare necessary to optimize health and well-being

Keep A Human Face On The Debate