1. Butcher, Lola

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Many cancer care practices are making major changes to improve the value of care they provide, believing that is the only survival strategy in the era of payment reform. But others are betting that demographics-an aging population that will supply an ever-growing number of cancer patients needing treatment-will keep them in business regardless of how their practices stack up, value-wise.

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Clifford Hudis, MD, a former president of the American Society of Clinical Oncology (2013-2014), thinks that latter group is thinking about the situation inaccurately: "There are sometimes some who imagine that we don't really have to do any of this, that we can continue as we were, that we can resist the change and wait it out," said Hudis, Chief of the Breast Medicine Service at Memorial Sloan Kettering Cancer Center. "And that's just not the case anymore."


Curtailing the rise in health care costs is a national imperative, in his view, and everyone must contribute to the solution. And that means payment reform.


Hudis discussed his thinking in a recent interview:


You were recently appointed to a new position at Memorial: Vice President for Government Relations and Chief Advocacy Officer. What does that position entail?

"It really is just another avenue for us at Memorial to get our point of view out there. In the same way that we constantly champion the power of investment in science and in clinical and translational research to improve care, we have, I think, an important contribution to make to the ongoing national discussion around broader policy issues, including issues like health care payment reform, but not limited to that.


"So this is a way of giving a voice to those opinions, and also, frankly, some of the development work that's done within our institution, looking at various alternative approaches to health care."


Both government and private payers are experimenting with new payment approaches that reward physicians and hospitals for the value of care they deliver, rather than the volume of care. How do you see NCI-designated Comprehensive Cancer Centers like MSKCC faring in this move to value-based care?

"I think in the end it's all going to boil down to how we measure and assess value specifically. Because I think that the contribution of the comprehensive cancer centers to the national ecosystem in terms of cancer care is immeasurable and important. These are the places where innovations most typically arise and are often first tested and even built out to scale.


"When you talk about value, one already has a challenge because there is the value that you might measure in a very conventional way to an individual patient and insurer, but there's the additional value to the nation and the world that these cancer centers provide. When we talk about measuring and rewarding value, I think we're going to have to develop some flexibility in terms of those issues, so that we don't penalize those who are innovating and leading.


"We will have to start with more conventional assessments. And the truth of the matter is outcomes, quality of life, even acute and chronic costs-these are all going to have to be factored into it. There could be some surprises along the way. One might find, for example, that certain high-cost centers are high cost for a short interval-let's say, early in the diagnosis and treatment-but when they deliver a better long-term outcome, their overall costs could be lower.


"I mention that because that immediately highlights another complexity in the health care system, which is, who is in it for the long term, and who is in it for the medium or short term? For example, some insurance companies could benefit if they were covering people for long periods of time, but they may not see that benefit when they're covering [a patient] for only a short interval. So that's an example of how we're going to have to think carefully about what we measure, and who is responsible in the end for paying."


You were recently quoted as saying "what is good for Memorial is what is good for the world in terms of research funding, insurance reform, and access to care." What is good for the world in terms of insurance reform and access to care?

"We can't escape several facts. One is that in the United States today, we spend about twice as much as the nearest high-income country on a per capita basis. And as an average, we don't deliver any better long-term outcomes. I'm quite precise in what I'm saying because I suspect that there are pockets of people within the U.S. who do far better than the average, and some of it may even relate to certain higher expenditures. But I don't know that.


"On the other hand, we do have, at least historically, a degree of disenfranchisement from access to care. So for having spent all of this money, it's not 100 percent clear what it is that we are getting. Indeed, when you look at it on a national level with the Gross Domestic Product approaching about 18 percent spent on health care, I don't know if that's right or wrong, but it is substantially more than other countries. And at some point in a very conventional, economic way, it infringes on the old guns-and-butter argument and might limit the ability of the country to innovate, grow, and respond to other non-medical external challenges.


"So we need some kind of a change. I don't think there's very much debate in the world that we could get many of the same outcomes that we get now, if not all of them, at somewhat lesser cost. In the end, I think everybody is going to benefit from innovation in payment for health care in the United States, even if what it means is a drive towards greater competition and perhaps a drive towards more accurate measurement of outcomes so that we can compete."


CMS announced plans for the Oncology Care Model earlier this year. Do you think the government is on the right track with that idea?

"This is a very complex question. Given the constraints and facts that already exist, I think that that is one reasonable model, and it's certainly worthy of careful pursuit, which is where they are right now.


"I think this raises a hidden issue, and I want to bring it out to the forefront. One of the problems that we have when we talk about health care in the United States is that, especially in the political arena, we often have very high-minded discussions about the need for free market forces, the need for competition, free enterprise, and conventional American economic approaches. The problem is-and I say this, I hope, with appropriate care-the problem is that we don't really fully admit the degree to which we have already agreed to a socialist model of health care.


"What I mean is that we have collective purchasing, we have collective regulations, we have collective agreement about minimal standards of care, we have collective agreements about what should be minimal access to care. And we try to implement all that while debating the kind of economic model we're going to use. That is a big challenge. And I actually have said that, unless and until we have a very honest discussion about the kind of health care payment system we truly have, it's going to remain difficult to try out alternatives. In the context of the system we do have, I think that their approach is a reasonable one to take."


ASCO has proposed its own payment reform model called Patient-Centered Oncology Payment. Is this idea in competition with the Oncology Care Model?

"To go back on my earlier point, this is an attempt to inject some degree of free market competition into this. If you have multiple models to test, you're competing them to see which one ultimately gets you closer to your aspiration-the goal of lower cost, higher quality, and more broadly available care.


"I wouldn't see them in fierce competition. I would see them in friendly competition. And I suspect that as the years go by, you're going to see borrowing and sharing from one model to the other in an attempt to harmonize the outcomes; you want to learn from what the others learn."


What do you want oncologists and practice managers to know about payment reform for oncology in the years ahead?

"First of all, I think one has to pay attention. In the same way that we approach the development of new scientific information and learning, we're going to have to invest some time in looking at the many options and models out there. The second thing is: People are going to have to know their own market, their own local environment, and to start, if you will, payment expectations and structures to figure out what might work best for them.


"It is important to emphasize is that, in the end, all of this is going to get back to the basic goals that we all share-that is, to deliver compassionate, empathic care. I think that when we do that, the value will follow, quite honestly. I'm not saying that people won't find examples and anecdotes where they seem to be in conflict, but I do think that in the grand scheme of things, being a good health care provider and doing the right thing is going to be rewarded."


Any parting thoughts?

"The only closing point I would make is that there are sometimes some who imagine that we don't really have to do any of this, that we can continue as we were, that we can resist the change and wait it out. And that's just not the case anymore.


"It is pretty clear that there is a shared civic responsibility and need to do something to change the rate of growth in the cost of care in general and some components of the cost of cancer care-making sure that we as a society get the highest value that we can for the significant amount of money that we spend. I think that's a fundamental good, and I hope that everybody understands that it's, if you will, a shared challenge that we can rise to."


iPad Extra!

For more details and specifics, listen to a podcast of the full interview with Dr. Hudis the iPad edition of this issue.


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