As the nation’s health care bill breaks the $3 trillion mark, it’s hard to imagine anything that would deliver a one-two punch capable of knocking down such unfathomable costs.
After all, experience has taught us that reining-in health care costs takes far more than a jab here and there. It’s going to take a systematic approach that demands that providers become far more efficient and effective in care delivery, and that employers and employees become vastly more informed consumers of health care services.
Attention Business Leaders:
Business leaders – your job, of knocking down health care costs, begins this minute. You have two, primary areas upon which to focus: 1) Initiatives designed to assess and improve the wellness and well-being of your employees; 2) Efforts to enhance the health literacy of your employees, as well as their ability to function as effective health care consumers. Chances are your HR department has already made significant strides in one or more of these areas, but there’s undoubtedly plenty of room for growth.
The initial steps are preparatory, and require that you:
Collaborate with your HR department (and any external employee benefits consulting groups that are actively engaged) to inventory all existing efforts related to wellness, well-being, health literacy, and enhancing health care consumerism.
Understand the metrics for measuring the impact of these efforts, and the corresponding gains that have been achieved since their implementation.
Review any employee surveys that have been conducted to assess attitudes and or interest in these topics – including reactions to proposed incentives or disincentives for participation in various health-related activities.
It’s Time to Plan:
Now that you know what has been done to-date, it’s time to develop a strategic plan that delineates additional methods for taking-down health care costs. Since you want the most efficient and effective strategies, a good place to start is with low-hanging fruit. In this case, that means identifying those areas where there is ample opportunity for improvement.
Begin by answering the following questions:
Do you have a cogent understanding of the health and well-being of your employed population – including: a stratified risk-profile of your employees derived from an HRA and/or biometric screening?
If so, what can be gleaned from this data to help you keep healthy employees healthy, while doing an ever better job of intervening to help manage chronic illness in the higher-risk population?
Do you have an effective program for managing chronic disease that is based upon best practices?
Have you assessed the health literacy of your employed populations, and implemented efforts to improve it?
Have you begun an educational effort to assist your employees in making value-driven decisions when selecting providers, choosing among treatment options, or requesting a prescription?
Have you aligned the incentives in your health plan to reinforce the behavior you hope to foster?
The more you, as a leader, understand about maximizing employee health, while reducing costs, the better prepared you will be to implement innovative strategies that are beneficial to the employee as well as your organization.
Leaders interested in becoming far more educated regarding the true nature of our health care system, may enjoy reading: The Myths of Modern Medicine: The Alarming Truth About American Health Care,Rowman & LIttlefield Publisher (2014). Author: John Leifer. It is available on Amazon.com.
Dr. Fata is an egregious example of profits over patients’ well-being.
Dr. Farid Fata, a Michigan hematologist oncologist, is simply the latest in a long list of physicians who have betrayed the trust of their patients, bilked the federal government of millions of dollars, and caused unnecessary pain and suffering for thousands upon thousands of patients. On July 10, Fata was sentenced to 45 years in prison based upon nearly two dozen counts of health care fraud, as well as a plethora of other charges.
Rarely are we more vulnerable than when facing a devastating illness like cancer. It’s a time when we often overwhelmed with anxiety, yet have to make decisions that may impact the balance of their lives; it is a time when we would like to believe, without reservation, that our physicians have our best interests at heart. Fortunately, the majority of the time, they do. But what of the exceptions? How do we protect ourselves against the unscrupulous doctors that abuse their cultural authority and the trust bestowed upon them?
There are clear steps you can take to safeguard their health when selecting a medical specialist and undergoing treatment. First, you need to take a very hard, data-driven look at your doctor. There are some basic questions you should be asking, including:
Is the physician Board-certified? Though Board-certification is no guarantee of either competency or ethical behavior, it does improve the likelihood of receiving appropriate medical care.
How long has the physician been practicing in his or her given specialty area?
Have there been complaints filed about the physician with your State Medical Board or can you identify legal action taken against the physician?
Does your primary care physician have an opinion regarding the competency of the specialist, and upon what is this opinion based?
Next, you need to understand your purported diagnosis and recommended treatment plan. Your physician should provide and interpret all of the results from your diagnostic imaging studies, laboratory analyses, and other tests. He or she should then explain, in terms you can understand, the best course of treatment to achieve a specific goal. In cancer care, there are three, potential goals: cure, control, or make one more comfortable.
Before agreeing to the recommended treatment, there are two, critical steps that will help ensure your safety. First, try to determine if the recommended treatment is considered a “standard pathway” or a generally agreed upon method for treating your disease. The National Comprehensive Cancer Network (NCCN.org) publishes guidelines for the treatment of most forms of cancer – including versions that are designed specifically for patients to review. If your physician’s recommendations deviate from these standards, you need to ask why.
Second, don’t hesitate to get a second opinion. If your physician balks or is not supportive of such action, find a new doctor. When seeking a second opinion, search out a specialist who has no affiliation with your current doctor. If there is a National Cancer Institute Center in your city, this may be a good place to start.
Doctors are every bit as mortal as you and I (trust me, I’m married to one…albeit a very good one). Fortunately, most physicians believe that it is a sacred responsibility to provide the best possible care.
We all know the saying about “a few bad apples.” When you find yourself faced with a serious illness, such as cancer, your job is to find the good ones!
“When you hear the word ‘cancer,’ it’s as if someone took the game of Life and tossed it in the air. All the pieces go flying. The pieces land on a new board. Everything has shifted. You don’t know where to start.” —Regina Brett[i]
A diagnosis of cancer can be overwhelming, but knowing a few basic things can help make the journey ahead far more manageable. Here are five key things you should know if you or a loved one has recently been diagnosed with cancer:
It is normal to feel completely overwhelmed when you hear the word cancer. Despite the anxiety, and accompanying sense of urgency to begin treatment, you must slow down and be methodical about the next steps.
Identify a caregiver who can be at your side throughout the journey ahead. Your caregiver will fill a number of important roles, including:
Serve as a scribe during your doctor appointments so that you have an accurate record of what transpires. This person can also be helpful in keeping other family members or loved ones informed.
Request copies of your records from all physicians seen related to your cancer. Be certain that the records include all imaging studies and pathology reports.
Help you navigate the complex health care system, while coordinating your care, as needed, across multiple physicians and treatment sites.
Provide essential emotional support.
Help you address basic functional needs at a time when many of your resources are consumed simply fighting your disease.
Before you can proceed, it is essential that you understand your diagnosis, the goals of treatment, and treatment options based upon objective information presented by knowledgeable physicians.
Oftentimes this requires visiting multiple specialists – including surgeons, as well as medical and radiation oncologists. Since there often numerous methods for treating a disease, these specialists may render differing opinions regarding what is best for you.
It is important to keep in mind that specialists have an understandable predilection for the types of interventions they deliver – a surgeon may be biased towards surgical procedures just as a radiation oncologist is biased towards radiation therapy.
Such differing opinions can be confusing for the patient…particularly since you are now navigating in unfamiliar territory. Before making a decision about treatment, there are three things that you must know:
As a general rule, the treatment should be based upon a “standard of care” – meaning that there is a consensus in the medical community regarding the best method(s) for managing your disease. The National Comprehensive Cancer Network, or NCCN, publishes such standards of care, or evidence-based pathways, for many types of cancer. Consumer-friendly versions of such pathways are available for free on their web-site (nccn.org). You would be well-advised to review the NCCN recommendations for your disease (and stage of disease). If your doctor is recommending a treatment that appears to deviate from the standards of care, ask him or her why.
There are pros and cons for every treatment – both in terms of the relative effectiveness of the treatment, as well as the short-term and long-term potential side-effects. Only by understanding these nuances of treatment can you make a truly informed decision about what is right for you.
There may be substantial differences in the costs associated with different interventions. While we all want and deserve the best treatment available, two treatments may be virtually identical in terms of the outcomes produced, but vary dramatically in costs. Before your out-of-pocket expenses grow astronomically, you may wish to discuss the projected cost of care with your doctors. Your physician should also inform you if he or she has a financial conflict of interest whereby they will profit more from the delivery of certain types of treatment. A urologist, for example who treats prostate cancer with a linear accelerator owned by the group has an ethical obligation to disclose this conflict to the patient.
Now that you are armed with far more information about the best course of treatment for your condition, you need to decide who will deliver your care and where you will receive it. Before you put blind trust in your doctors, you need to know that not all physicians (or facilities) are created equal – in fact, there’s tremendous variance in the relative quality of care delivered by different doctors at different hospitals/clinics. Unfortunately, sorting out the good apples is not the easiest task. Here are three suggestions for improving the odds of having a highly competent medical team:
Learn as much as you can about your physicians’ training, and experience treating your particular disease. There’s nothing wrong with interviewing your physicians! You should be sizing up your doctor, not only in terms of clinical training/experience/competency, but also how you feel at a gut-level about having them lead you through this difficult journey.
Keep in mind that practice does not make perfect, but when combined with the right training and certain inherent skills, it can make a huge difference. For instance, an oncologic surgeon who, after completing a fellowship in breast cancer surgery, has been practicing for ten years at a premier facility may produce different results than a general surgeon whose most frequent procedure is repairing a hernia. Unfortunately, there is no readily available data that allows us to compare the relative competency of our physicians.
Consider the depth and breadth of the cancer treatment resources available at your facility of choice. Do your best to separate out the marketing hyperbole from the cold, hard facts regarding the facility’s capabilities. It’s relatively easy to go to the hospitals’ websites within your community and compare capabilities. If there is an NCI-designated Comprehensive Cancer Center in your community (which differs from an NCI-designated Community Cancer Center), and have not selected it as your provider of choice, you may wish to get a second opinion at this facility. If you have an early stage, easily treated disease, this may be less of a concern than with more advanced or difficult to treat tumors.
Be careful about listening to the advice of your backdoor neighbor or cousin Martha about who the best doctor in town is for your cancer. Their intentions will undoubtedly be spot on, but their knowledge may be highly flawed. Author Marty Makary, M.D., a Johns Hopkins physician, talks about Dr. Hodad – a popular physician with a wonderful bedside manner whose patients think he walks on water (HODAD turns out to be an acronym for hands of death and destruction).
Never under-estimate the power of hope in helping get you through the journey. Though no one welcomes cancer into their life, a great many people experience tremendous growth as a result. Hope can be the force that helps you emerge on the other side…stronger, more resilient, and with a unique appreciation for the wonderful life you’ve been given.
There are many more steps to transforming an arduous journey into a manageable one. What I’ve outlined here are five of the most basic. If you would like to read more, I would strongly encourage you to read: After You Hear It’s Cancer: A Guide to Navigating the Difficult Journey Ahead.
The high costs of cancer drugs puts them out of reach for many patients.
Beyond the caring rhetoric carefully crafted by providers of cancer treatment and therapeutics, there exists a motivation every bit as powerful as saving lives — reaping billions of dollars in profit. That’s what is at stake in the ongoing war on cancer — a war in which important battles have been won, but at a tremendous cost.
As the number of cancer patients grows and their treatments become increasingly expensive, we will find ourselves locked in an unwinnable war of attrition…unless reining-in costs becomes as much of a priority as expanding our medical armamentarium.
How the battlefield changed:
Despite the fact that cancer incidence rates have declined for the most frequently occurring types of the disease, cancer continues to impact 40 percent of all Americans, and it is responsible for 20 percent of all deaths. That translates into 1.66 million newly diagnosed patients annually and nearly 600,000 deaths, according to the National Cancer Institute. Incidence tells only part of the story, however. More importantly, the majority of cancer patients are surviving longer.
There are currently more than 14 million Americans who have survived cancer—a dramatic increase from the 3 million survivors in 1971. While much of this increase is attributable to population growth, improvements in cancer therapies have also played an essential role. As a result, for many patients, cancer has been transformed from a death sentence into a chronic disease that perhaps cannot be cured, but can be controlled for an extended period of time.
The soaring costs of care:
Fifty years ago, direct spending on cancer care equaled $1.3 billion. By 1995, spending had soared to $41.2 billion, and by 2010, it was an estimated $125 billion. That’s an almost 10,000 percent increase in direct spending over fifty years. Add in the indirect costs of care, such as lost productivity, and the numbers almost triple.
Cancer care was not the only part of the nation’s health care bill that rose dramatically over time. In 1950, total health care costs for the U.S. equaled $12.7 billion. By 2012, those costs had risen to $2.6 trillion – a 20,000 percent increase in the span of three generations
Such costs have taken quite a toll. Today, the single greatest cause of personal bankruptcy in America is medical bills. In fact, “The percentage of personal bankruptcies in the United States attributed to health care costs rose from 46.2% in 2001 to 69.1% in 2007.” Such statistics come as no surprise, since patients are bearing an increasing proportion of the cost burden associated with expensive treatments. Medicare beneficiaries who are often on a limited, fixed income are particularly hard hit.
What Lies Ahead:
The estimated cost burden for the coming decades is fuzzy at best. The NIH guesstimates that the direct costs of cancer care could range anywhere from $158 billion to $207 billion. A number of factors are contributing not only to cost escalation, but also to the complexity of forecasting.
We know that the projected level of growth in the 65+ segment of our population—which is the segment most affected by cancer—will result in a virtual tsunami of cancer patients. What we don’t know is how these patients will be treated, or the costs of emerging therapeutic modalities.
Furthermore, with the number of cancer survivors forecast to grow to 19 million by 2024, there will presumably be a dramatic increase in the long-term costs of controlling their disease and maintaining their well-being.
History demonstrates that the cost of cancer does not increase linearly, but rather in a manner reminiscent of Moore’s law—a factor that proves beneficial when describing the growing power of computers, but not the growing costs of care. Nowhere is this more apparent than in the skyrocketing costs of pharmaceutical products.
A Pharmaceutical Gold Rush
The pharmaceutical industry has doubled-down on its investment in cancer therapeutics—a wise move, considering the increased market demand reported by industry monitor, IMS: “The global market for oncology drugs, including those used in supportive care, reached $91 billion in 2013…this compares with $71 billion in 2008 and $37 billion a decade ago.”
With demand soaring and sales burgeoning, much of pharmaceutical research now centers on beating cancer. IMS concluded that, “cancer therapies account for more than 30 percent of all preclinical and phase I clinical development products…”
It’s not just demand that is driving the soaring sales of cancer drug. It’s the manner in which drugs are priced. In the U.S., which accounts for 40 percent of all cancer drug sales, there are no governing rules regarding pricing, beyond what the market will bear. While most consumer products are priced based upon comparative value, the price of cancer therapeutics appears to be plucked from the ether with no relationship to the drug’s relative efficacy or toxicity.
Don’t take my word for it, look at the numbers: According to an article in the Journal of Clinical Oncology, “Of the 12 anticancer drugs approved by the FDA in 2012, only three prolonged survival, two of them by less than 2 months…yet nine were priced at more than $10,000 per month.” One drug, approved for the treatment of pancreatic cancer, was shown to extend survival by a mere 10 days.
According to an article published by the Mayo Clinic, “Last year, ipilimumab (Yervoy; Bristol-Myers Squibb, New York, NY) was approved by the Food and Drug Administration (FDA) for the treatment of metastatic melanoma. The benefit in survival over and above standard treatment was 3.7 months in previously treated patients and 2.1 months in previously untreated patients. The cost: $120,000 for 4 doses.”
It appears that $100,000 per year has been set as the minimum threshold for introducing new cancer therapies. But it is not just the introductory pricing of drugs that is problematic. It is also the price inflation of cancer drugs that is raising costs astronomically. The price of imatinib, a drug used to treat CML (chronic myeloid leukemia) increased from $30,000 to approximately $90,000 over a ten-year period.
Lies, Damn Lies, and Statistics:
The pharmaceutical industry justifies what appears to be morally egregious behavior by explaining that drug costs are primarily driven by research costs. In fact, stating that the cost of bringing a drug to market now exceeds $1 billion has become almost a mantra—but it is patently invalid.
Pharma’s argument regarding the tremendous costs of research was effectively eviscerated in a November 15, 2013 article in the prestigious journal Cancer. Authors Donald Light, Ph.D., and Hagop Kantarjian, M.D., demonstrated that the actual cost probably approaches $125 million or one-eighth of what has been claimed.
You Don’t Have to Sell Drugs to Profit from Cancer:
It’s not just pharma that is profiting from this gold rush. Cash-strapped hospitals and health systems are lining up to ensure that cancer provides a rosy bottom line for their institutions.
Not only are facilities expanding the depth and breadth of cancer services offered, but they are now employing oncologists at an unprecedented rate. Such employment accomplishes multiple objectives: 1) It locks in the physicians who control patient flow in the market, thus locking in market share; 2) it allows the hospitals to increase the costs of the oncologists’ services by billing them as hospital outpatient services; 3) it allows hospitals to capture all the procedural revenue—imaging, radiation, and surgery—associated with these patients; 4) it allows hospitals to increase profits on the resales of cancer drugs using what is known as “340b” pricing.
Numerous other parties stand to profit handsomely from the growth of cancer—including, but not limited to health information technology companies that seek to capitalize on the tremendous data-demands associated with cancer research, medical technology vendors, and even manufacturers of prosthetics.
Re-establishing equilibrium between Patients and Profits:
Until payers realign incentives so that providers are rewarded based upon achieving the most efficient and effective patient outcomes over time, there will be an imbalance between the needs of patients and the pull of profits.
There are specific steps that can be taken today to achieve these objectives, including:
Physicians must act as fiduciaries for their patients’ health and well-being. As such, they must demand comparative effectiveness data that show the relative value of a cancer drug. Physicians can drive change simply through their prescribing patterns, and they must wield this power appropriately on behalf of their patients. This principle was proven effective when a group of oncologists at Memorial Sloan Kettering refused to prescribe the drug Zaltrap because it was twice as expensive as an alternative drug yet no more effective. The manufacturer bowed to the pressure and cut the price of Zaltrap by 50 percent.
The FDA can aid these efforts to move from “what the market will bear” pricing to value-based pricing by establishing minimal thresholds for comparative efficacy while also factoring in the comparative toxicity of drugs under consideration. .
There must be clear and unequivocal prohibitions on any conflicts of interest that allow physicians to profit, beyond their professional fees, for the provision of cancer therapeutics—be it a chemo agent, radiation treatments, or other modalities.
The Department of Justice must bring greater scrutiny to the acquisition of major oncology groups or other actions that may result in the creation of monopolies or oligopolies in cancer care.
Congress must reconsider the prohibitions on governmental agencies, such as Center for Medicare and Medicaid Services (CMS), from negotiating prices with pharmaceutical manufacturers.
As a society, we must struggle with through discussions of what we are willing to expend in order to extend life, while factoring in the patients’ probable quality of life. Discussions of “death panels” must yield to rational, albeit difficult conversations.
The Time to Act is Now:
Health care providers and vendors have proven that they are incapable of being self-regulating. They have also proven that they are subject to the same moral vices as the rest of society, including greed. There needs to be immediate action to stop the profiteering off the backs of cancer patients, while war of attrition, simultaneously using our health care dollars wisely in the quest to conquer cancer.
PLEASE VISIT THE WEB-SITE FOR MY NEW BOOK, After You Hear It’s Cancer: A Guide to Navigating the Difficult Journey Ahead: www.afteryouhearitscancer.com
Solutions to health care’s plethora or problems require unique thinking.
Imagine that you are scanning through resumes of your latest job applicants, and you come across an individual whose job history includes: university professor, healthcare executive, consultant, professional photographer, karate instructor, advertising executive, executive coach, and author? Would you discard it out-of-hand concluding that the applicant was a wacko malcontent or would you say, “Wow, a renaissance man?”
While the average American will change jobs 11 times over his or her lifetime, rarely do such changes involve complete reinvention of one’s career. Such tectonic shifts in our professional lives are understandably pathologized by a society that rewards stability, and frowns on unpredictability.
Yet, far from being pathological, such shifts may identify individuals motivated by a profound need for meaning in their lives rather than by the rewards associated with climbing the corporate ladder. Though such individuals may grace an organization but for a short time, if properly managed, their positive impact can be profound. After all, if they can successfully reinvent themselves on numerous occasions, imagine what they can do relative to innovation in your corporation!
So what traits do these professional shape-shifters have in common? Here’s a list – what’s important here is to know what your organization can and cannot live with before bringing this rare creature on-board:
#1: Innovators have difficulty following standards pathways or protocols…preferring to intuitively seek out more efficient or effective ways of managing challenges. Their solutions are often far outside the box.
#2: Innovators are relatively intolerant of organizational resistance to change –neither understanding nor appreciating the value of an organization’s muscle memory. They are the antithesis of the legions of Six Sigma black-belts of whom your organization may be so proud. Innovators are the employees who will poke management with a sharp stick if they fail to get the response they seek.
#3: Innovators are relatively fearless when it comes to change…change is as natural a part of their lives as breathing. Their worth and identity is not tied to the current job…it is based upon where they are at in their existential search for meaning.
#4: They do not suffer fools well…and can exhibit amazing impatience when they perceive that they are dealing with ignorance.
#5: They may disregard corporate protocol as being superfluous and annoying…including such things as chain of commanded.
#6: They may not filter what they say or how they say it. After all, it is the truth, from their perspective, and, as such, needs not to be framed or apologized for.
#7: They do not revere loyalty in the traditional sense. You won’t be rewarding these innovators with a gold watch after 30 years of service. The most you can hope for is to part company as valued colleagues…and wish the innovator well as he or she moves on to yet another reinvention.
Such individuals need to have a culture that can embrace and adapt to their idiosyncratic nature. Many of these traits are immutable, though good innovators can be coached on how to get their ideas across in a semi-politically astute manner.
If you can create the right conditions for such an innovator, you should expect:
The potential for radical, out of the box thinking that will outstrip any linear planning processes currently in place in your organization
The potential for vision that seeks possibilities previously completely oblique to your organization and leadership team.
Ways of creating synergies that were not previously identified
The ability to challenge and catalyze positive change in your corporate culture
The ability to attract great talent to your team
Where do you find such individuals? First, you have to open your eyes to the possibilities. One of the most innovative thinkers I ever hired was a gentleman applying for a copy-writing position with my company. Though he had never been in such a position before, he proudly proclaimed that he would be, in short order, the best copywriter in town. His resume was eclectic, to say the least…including past job jobs as an exterminator and manager of a low-income housing project, while also having earned a Ph.D, and being honored as a Fulbright Scholar. What matters most is that he lived up to his boastful claim – he became a superlative writer with highly innovative ideas.
I am writing this post because I work in the health care arena, where transformational change often times seems to be an oxymoron, and problems are resolved at a glacial pace. I’m convinced that, if we are to address the plethora of complex issues that keep our health care system from delivering safe, affordable, high quality care, a good starting point would be to replace our black-belts with new true innovators…and then step out of the way and empower them to work their magic.
As the nation’s health care bill breaks the $3 trillion mark, it’s hard to imagine anything that would deliver a one-two punch capable of knocking down such unfathomable costs.
