Transforming America’s Healthcare

Edward E. Partridge, MD, DirectorUAB Comprehensive Cancer CenterProfessor of Gynecologic Oncology

Evalina B. Spencer Chair in Oncology

Alternate Title

The Budget Deficit

US Healthcare

This Disparities Thing

The American Cancer Society

We are dedicated to helping People:• Get Well• Stay Well• Find Cures• Fight Back

How Can We Provide Adequate High Quality Care (to Include Preventive Care) to a Population That Has So Often Not Received It?

8090

100110120130140150160170180190200210220

75 78 81 84 87 90 93 96 99 '02 '05 '08 '11 '14

All Sites - Mortality RatesAll Sites - Mortality RatesBy Year of Death - All Races, Males and

Females2015 Goal – 50% Reduction from Baseline

1991 Baseline 215.1

2015 Goal 107.6

Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard populationSEER Cancer Statistics Review 1975-2007.

2007 178.2

( 17.2% from baseline)

(Current trend to 2015 - 30.0% from baseline)(The latest joinpoint trend (2001-2007) shows a -1.6 APC in age-adjusted rates)

2015 Projected

Rate – 150.6

Deaths averted from 1991-2020

The blue solid line represents the actual number of cancer deaths recorded and the blue dashed line represents projected cancer deaths based on decreasing trends in cancer death rates during 2003-2007. The green dashed line represents the projected number of cancer deaths if rates continue to decline at twice the current rate (2003-2007) beginning in 2013. The red line represents the expected number of cancer deaths if cancer death rates had remained the same since 1990 (males) and 1991(females).

Beyond Healthcare Reform

• What was that Debt Limit Debate really about.

• Federal Medicare/Medicaid costs are spiraling out of control

• In 2010, 23% of the $3.456 Trillion Federal budget ($793 Billion)

Beyond Healthcare Reform

• Medicare, Medicaid, and Social Security account for all of the projected increase in Federal spending over the next 40 years.

• For the past 30 years, costs per person throughout the health care system have been growing approximately two percentage points faster per year than per-capita GDP.

• Most projections assume this pattern will continue through 2050. Over time, the fiscal consequences of this rate of growth in health costs aremassive.

Factor Increasing Cancer Risk in U.S.

• The Aging of the population– 30 million over age 65 in 2000– 71 million over age 65 in 2030

• Western diet/high in calories

• Lack of exercise

• Smoking/Tobacco use

True Healthcare ReformRequires:

• Broad critical thinking• The use of “Evidence Based Care and Prevention”

That is: the rational use of medicine not the rationing of medicine

• We do what we know works and often do not do• We stop doing what we know does not work

Toward an Efficient Healthcare System

• Some consume too much – (Unnecessary care given)

• Some consume too little– (Necessary care not given)

• We could decrease the waste and improve overall health!!!!

U.S. Health Care Spending

In 2009, the U.S. spent

$2.53 TRILLION on Health Care

U.S. Health Care Spending in Context

•How Big is a Trillion?

1 million seconds Last week

1 billion seconds Richard Nixon’s Resignation

1 trillion seconds 30,000 BCE

Spending in Context

2009

*Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion)

Source:Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis

$2.53 trillion

$1.1 trillion

$1.4 trillion

Gross Domestic Product

American Healthcare

• 16.2% of GDP in 2006• 17.3% of GDP in 2009• 19.3% of GDP by 2019 (projected)• 25% of GDP by 2025 (projected)

Spending: US vs. Other Countries

Per capita health care spending, 2006$ at PPP*

Per capita GDP ($)*Purchasing power parity.

** Estimated Spending According to Wealth. Source: Organization for Economic Co-operation and Development (OECD)

US Healthcare Outcomes

• Are generally worse than in other western countries

• True for cancer and other chronic diseases

• Canada is a wonderful place!!!!

Healthcare in Three Countries (2010)

• Canada Switzerland U.S. • Infant Mortality 5.04 4.53 6.22 per 1000 live births

• White Male Life Exp 78.0 79.7 76.8 Years

• Per Capita Costs 3173 4011 6096 US Dollars

• Proportion of GDP 9.6% 11.2% 17.3%

Overall Quality: Life Expectancy at 65

The US is ranked 12th for Males and 16th for Females

Source: OECD, 2006 data

U.S. vs. Canada

• CT Scanners per million population. U.S. dominates by 3 to 1 ratio

• MRI Scanner per million population. U.S. dominates by 5 to 1 ratio

True Healthcare Reform(An Efficient, Value Driven Health System)

• Rational use of healthcare is necessary for the future of the U.S. economy (an issue of U.S. security)

• It is possible to decrease costs and improve healthcare by using science to guide our policies

• We need to be smart about health

Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB

Equal Treatment Yields Equal OutcomeThere is not Equal Treatment

Studies suggest that disparities in treatment may be due to:

• Cultural differences in acceptance of therapy.• Disparities in comorbid diseases (including

obesity) making aggressive therapy inappropriate.• Lack of convenient access to therapy.• Racism and SES discrimination.

How Can We Provide Adequate High Quality Care (to Include Preventive Care) to a Population That Has So Often Not Received It?

The Future of Healthcare

Are American’s willing to be scientific, accept scientific reality and

Give up “faith based medicine”

and Adopt and appreciate “evidence based medicine?”

Medical Gluttony

• Screening tests of no proven value• Treatments of no proven value• Laboratory and radiologic imaging

done for convenience.• -Cannot find original.• -Legal defense (real or

imagined).• -Tradition.

Treatment versus Prevention

• Our healthcare system is heavilly focused on addressing illness.

• The system needs to transform to one that places more value on prevention and early detection of disease!

Clinical Lessons Learned Late

• Postmenopausal Hormone replacement therapy-• Lidocaine after MI • Hyper-vitaminosis (Vit E, Beta Carotene, Selenium)• Rofecoxib and Celecoxib for arthritic pain

– (Vioxx and Celebrex)• Rosiglitazone (Avandia) for diabetes• Erythropoetin

Clinical Lessons Learned Late

• Hysterectomy• Caesarian section• Carotid endarterectomy• Coronary Artery Bypass Grafting• Tonsillectomy• Tympanostomy

Clinical Lessons Learned Late

• Chest X-ray screening for lung cancer• Urine screening for neuroblastoma• Cryotherapy for prostate cancer• Halsted mastectomy• Adjuvant bone marrow transplant for breast cancer

Screening

• Breast - Mammography and Clinical Examination

• Colon – Stool Blood Testing, Sigmoidoscopy, Colonoscopy

• Cervix – Pap smear (conventional or wet)

Screening

• Lung – Spiral CT, 20% decrease, significant side effects of screening`

– 99.5% saw no benefit– 0.5% were helped (death prevented)– 3.5% were harmed (unnecessary surgery)– 0.6% were harmed (complication of surgery)

Screening

• Lung – Spiral CT, 20% decrease, significant side effects of screening`

– 1 in 217were helped (death prevented)– 1 in 4 were harmed (false positive CT)– 1 in 30 were harmed (unnecessary surgery)– 1 in 161 were harmed (complication of surgery)

Fact

• Smoking cessation is more powerful at preventing lung cancer death than spiral CT screening.

• It is also cheaper!!!

Screening

•Prostate – PSA, effectiveness is a question mark and still the focus of study

ACS Leadership Roles

Prevention and Early DetectionLeadership Roles

• Breast cancer• Colorectal cancer• Reduce tobacco use• Nutrition and physical activity

Breast Cancer

There has been a 30% decline in breast cancer death rate since 1991 (57,000 deaths averted)

•Treatment has improved dramatically•Screening Rates: 53% by NHIS

62.1% by BRFSS•A substantial number of women get less than high quality healthcare.

Prevention and Early DetectionLeadership Roles

• Breast cancer

• Colorectal cancer• Reduce tobacco use• Nutrition and physical activity

Colorectal Cancer

There has been a 30.4% reduction in colorectal cancer mortality since 1991 (77,000 deaths averted)

•Treatment has improved dramatically•About half of Americans over 50 get any screening.•A substantial proportion of Americans get less than high quality screening and treatment.

Breast CancerThe Reality

• From 1993 to 1997, 561 Black women died of breast cancer in Atlanta.

• If Atlanta’s Black population had the Department of Defense Health System Black rate, 330 would have died (231 less)

• Lund et al, Cancer 2004

Prevention and Early DetectionLeadership Roles

• Breast cancer• Colorectal cancer

• Reduce tobacco use• Nutrition and physical activity

Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2008

*Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over. Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

Men

Women

Lung Cancer•14.1% reduction in mortality to 2009

–2009 adult smoking prevalence of 20.6% (CDC National Health Interview Survey)

–2009 teen smoking prevalence of 19.5% (CDC Youth Risk Behavior Surveillance System)

Prevention and Early DetectionLeadership Roles

• Breast cancer• Colorectal cancer• Reduce tobacco use

• Nutrition and physical activity

Poor Nutrition and Lack of Physical Activity•Obesity, high caloric intake, and lack of physical activity is increasing rates of:• Diabetes• Cardiovascular Disease• Orthopedic Injury• Cancer

Nutrition and Physical Activity

• Obesity, high caloric intake, and lack of physical activity has the potential of being a greater cause of cancer in the U.S. than tobacco by 2030

• We are currently not able to model this in an acceptable fashion but it is causing a rise in cancer incidence

Summary of Cancer Mortality by Body Mass Index Women

Relative Risk and 95% CI(based on never smoking women)

0 1 2 3 4 5 6 7 8 9 10 11

6.34.8

3.2

2.82.6*2.5*

2.12.1

2.01.9*

1.7

1.5

1.5

1.4

Calle et al. NEJM 2001

Breast (> 40)

Ovarian (> 35)

NHL (> 35)

Kidney (> 40)Uterus (> 40)

Liver (> 35)

Colon & Rectum (> 40)

Multiple myeloma (> 35)

All other cancers (> 40)

All Cancers (> 40)Esophageal (> 30)Pancreas (> 40)Cervical (> 35)

Gall bladder (> 30)

0 1 2 3 4 5 6 7

4.5

2.6*

1.9

1.9*

1.8

1.8

1.7*

1.5

1.5

1.3

1.7

1.7

Summary of Cancer Mortality by Body Mass Index Men

Relative Risk and 95% CI(based on never smoking men)

All cancers (> 40)

NHL (> 35)

All Aother cancers (> 30)

Kidney (> 35)

Multiple myeloma (> 35)

Gall bladder (> 30)Colon & Rectum (> 35)

Esophageal (> 30)

Pancreas (> 35)Liver (> 35)

Prostate (> 35)

Stomach (> 35)

Calle et al. NEJM 2001

Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2008

*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category.Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-06: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05. 2007-08: Ogden CL, et al. Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA 2010; 303 (3): 242-249.

54

65

75

7

11 1110

16 16

12

1718

10

2018

0

5

10

15

20

25

2 to 5 years 6 to 11 years 12 to 19 years

Pre

va

len

ce

(%

)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-06 NHANES 2007-08

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2008†

*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: 1976-2006: National Health and Nutrition Examination Survey, Hispanic Health and Nutrition Examination Survey (1982–84). Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2008, With Special Feature on the Health of Young Adults. Hyattsville, Maryland: 2009. 2007-2008: National Health and Nutrition Examination Survey Public Use Data File, 2007-2008 National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

1311

1615

12

1715

13

17

2321

26

3128

3433 333535

33

36

0

5

10

15

20

25

30

35

40

45

Both sexes Men Women

Pre

vale

nce

(%)

NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-06 NHANES 2007-08

Note: Data from participating states and the District of Columbia were aggregated to represent the United States.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.

24.2 24.4 24.1 24.4 23.6 24.3 24.7

0

5

10

15

20

25

30

35

1994 1996 1998 2000 2003 2005 2007

Year

Pre

vale

nce

(%)

Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007

Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2008

Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older.Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000 to 2008), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997-2009.

Adults with less than a high school education

All adults

The American Cancer Society

We are dedicated to helping People:• Get Well• Stay Well• Find Cures• Fight Back

Three great threats to America’s Future

• Apathy• Ignorance• Greed

Reforming how healthcare is paid forVs.

Transforming how we view and consume it

Transforming American Healthcare

Issues:•Irrational patterns of consumption•A lack of basic prevention (obesity, smoking)•A lack of education (scientific fact)

How Can We Provide Adequate High Quality Care (to Include Preventive Care) to a Population That Has So Often Not Received It?

Breast Cancer Screening

The Reality:•With maximum use of current technologies. More than 450,000 women will still die of breast cancer over the next decade.•Let us use mammography, but not be content with it (my opinion). •Let us support research to improve mammography, find better tests and better treatments.

American Urological Association

• Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical.

• Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.

• PSA Best Practice Statement 2009

European Association of Urology

• Recommends against mass screening.• Recommends for informed decision making within the

physician-patient relationship.

– “Men should obtain information on the risks and potential benefits of screening and make an individual decision”

– European Urology 56(2), 2009

National Comprehensive Cancer Network

– “ There are advantages and disadvantages to having a PSA test, and there is no ‘right’ answer about PSA testing for everyone. Each man should make an informed decision about whether the PSA test is right for him.”

“Men should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.”

The American Cancer Society 2010

Prostate Cancer Screening Guideline