VBCC - June 2012, Volume 3, No 4 - Best Practices

Value-Based Cancer Care is focused on examining value within the context of healthcare stakeholder relations. Dr Pecora and his team at Regional Cancer Care Associates (RCCA) have changed the relationship between the practicing oncologist and the payer, which will have substantial effects on value. For years, the signs were clear that for oncologists to survive and be in a position to implement the great advances in treatment, they would require a new business model, and Dr Pecora and RCCA have provided one.

RCCA has consolidated independent small practices into a major consortium, redefining the balance of power between provider and payer, freeing the providers to focus on the individual patient.

Value-Based Cancer Care (VBCC) asked Dr Pecora to describe how oncologists can survive and implement advances in cancer treatment through a new business model that is focused on patient outcomes, stakeholder viability, and value-based care.

VBCC: What forces motivated the consolidation that RCCA provides, and what are the clinical and economic components contributing to the success of RCCA?

Andrew Pecora, MD, FACP, CPE: We use a lot of buzz words. But at the end of the day, what do patients with cancer want? They want to live. They don’t want to die. They want to be offered the best possible therapy; cancer, in addition to causing much fear, is very inconvenient. Patients need convenience.

Patients require access to care. That’s the first layer of developing a product. Let’s say that cancer care was a product that we wanted to develop. We know there is a market for it, although no one has ever seen it before, and here is what it needs to do. That was the approach advocated by the group of doctors who formed RCCA.

When we looked at high-quality, cost-efficient cancer care, we believed that no one but us should be the ones developing it. This is what we were all trained to do, and what we have been doing for 30 or 40 years. Many of us are professors of medicine. We are well regarded in our opinions. We write book chapters, papers, and so on.

Yet, everyone else was saying, “This is how we should do it, and this is why.” Given the power of economics, the power of scale, and the power of controlling the dollar, it just did not seem like there was any sensible way for the people who actually delivered the care to do it, other than coming together with the understanding that there needs to be a new product offering.

Value-based cancer care cannot mean one thing to a payer, something else to a doctor, and a third thing to a patient. It has to mean the same thing to everybody. And we are going to drive that by having an entity that is of substantive size and scale, which will get attention in the marketplace. Then, if you have a good product, you need to be able to deliver on that product.

We created RCCA based on the idea that like-minded physicians could come together in one entity. We are one practice. We are not a confederacy of practices, and there is not a practice management model with everyone keeping their own entity. As one entity, we have assumed the responsibility of delivering what we consider to be a high-quality, cost-efficient product, which is cancer care for each type of cancer.

VBCC: No field of medicine is more innovative than oncology. People have always been donating for cancer research. It has been driven into the American culture that overcoming cancer and doing research for its cure is an enormous priority. Are we now getting our wish?

Dr Pecora: Yes, we are getting our wish, but ironically, we are being told that we cannot afford it. And then we are being told, “Don’t do it,” or we are asked, “Why are you keeping these people alive so long?” and, “Is it really worth it to give them this medication that only adds 4 months to their survival?” If you dissect these arguments to their natural conclusions, it would make for great comedy, or maybe tragedy, depending on your perspective.

The National Cancer Act of 1972 set in motion, globally, a consequence that has transformed biology. Many of the discoveries in molecular biology come out of understanding cancer and its many positive consequences, and all of the wonderful new drugs. I can now offer patients with metastatic melanoma a drug that extends survival, but I have payers saying, “Yes, but it is only for 1 month,” and asking, “Is it really worth it?”

The ultimate conflict for a physician is to go into a patient’s room. Do I wear my “I have to do what is good for society” hat and make sure that we are competitive in the global marketplace as a business and have proper healthcare margins? Do I wear my “doctor hat” and say, “You really want this drug, because it may extend your life,” or do I wear my “ethicist hat” and ask, “Did I discuss the value of that next 4 months enough with this person? Should I help the patient decide that hospice may be the better way to go?” I am going to have to do all of this in 10 minutes and 32 seconds, because I am reimbursed approximately $40 to do this, and I have to see 30 people a day just to keep my office open. This is the embodiment of what is going into a doctor ’s decision process. I do not mean to be glib, but that is the truth.

VBCC: We all have to come to grips with the concept of value as a balance of cost and quality and understand how to implement it. If you become a cost zealot you are going to do so by reducing quality, access, or both. Conversely, if you come up with treatments that are profoundly helpful, but they consume the entire Gross National Product, you have not really done anyone a favor. Does there have to be some common sense on the part of researchers?

Dr Pecora: Yes, but who adjudicates that in real time? You cannot adjudicate that outside of the bedside. Value is not for a group discussion. It is not for a committee. That is why they call it the “death panel” in the United States and NICE (the National Institute for Clinical Excellence) in Europe. NICE involves a small group of people deciding who lives, who dies, and how long you live or die.

RCCA intends to show that you can save millions of dollars without adversely affecting quality of care, but you can only save millions of dollars if you are willing to recognize that millions of dollars are being spent around healthcare, enriching people around healthcare. Millions of dollars are being spent legislating healthcare. There is no business like it in America.

If you take all of those dollars and can change the system even a little bit, and move the needle a little bit, there will be lots of money or resources available, so that you do not have to say to a person, “This drug can improve your survival by 4 months, but we cannot give it to you.” What RCCA and others like it need to do is assume our responsibility. We are the experts in cancer care delivery, the federal government is not. The Centers for Medicare & Medicaid Services is not; they do not provide cancer care. Blue Cross does not provide cancer care; they pay for it.

How do we do that? Doctors were never trained to think this way, and they do not have the tools. Even if you have 2 or 3 doctors who do everything perfect, it does not move the needle. But now you put together a network of doctors like we have, who represent approximately 40% of all cancer in New Jersey, and if we start moving the needle, (1) it will be measurable, and (2) it will have an effect.

We realize that, and that is why we are here—to assume the responsibility of providing high-quality, transparent cancer care. We have some ideas about how to do it, because this is what we do.

VBCC: You have pointed out that the greatest dangers to the costs of care and oncology are the inefficiencies that come from legislation by people who really do not understand oncology, which is what you refer to as the cost of legislation in trying to systematize something that is inherently a personalized medicine process. What are the main problems with the inefficient financial aspects that plague oncology?

Dr Pecora: In general terms, one is site of service. We have to move sites of service from expensive sites to less-expensive ones. Hospitals do not have to be the most expensive site of service, but they can be. You do not need to come to an office and spend time, money, and gas, and generate an office charge when something can be done at home. How do you do that at scale? How do you do it in a way that is not averse to the people who are actually doing it, so they are rewarded for doing it? That is one big area.

The second large area is, do what is needed, but no more and no less.There are many examples where tests that are critical to help make a decision— do you go in direction A or B?—are not done. You either do not know, or you are getting too many tests. You are seeing all of the recent news on that. How do you systematize that in a way that is business-efficient? That is another.

The third area is how to deliver personalized cancer care, down to the level of genomics, at scale in a business-efficient way. You can waste a lot of time and money giving a drug therapy that has no hope of working, if you only knew a certain gene was not in the right direction. How do you do that? That is what RCCA intends to do. We are already at scale, given our size and volume, and we know how we can do that. We believe we are going to be able to move the needle and demonstrate higher quality and more cost efficiency, and do it transparently.

VBCC: Can you provide a brief summary of your protocol, your structure that provides for these services and output?

Dr Pecora: We are all 1 business, 1 provider number, 1 corporation, 1 entity. It is not a management service company. That is unique.

VBCC: In the past, what was preventing medical associations, such as the American Society of Clinical Oncology (ASCO), from solving the problem? Why did it require physicians in the trenches to realize and act on this?

Dr Pecora: There are plenty of people who know what needs to be done, but there are fewer people who can actually execute it. We at RCCA can execute it. That is the difference.

VBCC: There are a lot of guidelines in cancer care. How does your organizational process benefit from them? How much latitude do you have in determining which tests to perform? How does RCCA’s approach impact the process of care?

Dr Pecora: Going back to the concept of a product, there are plenty of circumstances in cancer care where it is straightforward what you want the product to be. That is what we need to be able to do well, and we have to be able to demonstrate that we are doing a good job. It is not just the drugs we choose to give or the procedures, but it is also how we follow up with the person. You will see a lot more of that from RCCA in short order.

The other side of it, however, is that sometimes you don’t know what you are trying to make, because you are not quite sure what the issues are. That is where the other arm of RCCA, being a major engine of discovery, is going to be important. We plan on working with the evolving genomic-based personalized medicine industry, so that we can look at a tumor in a way that we could not before, and make a specific decision to give or not to give a treatment, on an individual-patient basis, based on what the DNA of the tumor is telling you to do.

That is not science fiction anymore, and it is coming pretty rapid. We need to be able to integrate that at scale—to offer patients high-quality, cost-efficient care in their local community so that access is not an issue, and to make certain that doctors are following preagreed guidelines. The consensus was there from the start. They have agreed on them, and they have said, “We’ve all agreed, and we have a methodology for how we do that. We all agree this is the right way to go, and if some new information comes in, we change what we do then, and we do it in real time.” But, also, they have formed this consensus to be part of this vanguard of better characterization of patients so that they may receive optimum care.

What matters is that they can do that at a corporate scale level of RCCA. As I said before, if I do this in my office, and I am a 3-man practice, even if I were the best in the world at it, I would not be moving the needle at all. But if I do this at the scale of RCCA, I am going to move the needle and be rewarded for it, and that is like a feedback cycle. I do something, I get rewarded for doing something that brings value to the system, and I want to bring more value to the system. This is no different from any other entity: you do something, you get rewarded for it, you want to do more of it.

VBCC: Are you able to leverage the advantages of biologics and of the personalized care that is out there?

Dr Pecora: Yes, absolutely, through new efficiencies and removing the distractions. It is a huge distraction if you are an oncologist walking into that hypothetical room and one third of your brain is supposed to be an economist, one third is supposed to be an ethicist, and one third is supposed to be a brilliant biologist/clinician. You have to adjudicate all of these things we talked about, and then you step outside and you realize you need a computed axial tomography scan for someone who just came in and is coughing up blood.

You have to spend 20 minutes on the phone getting approval from a secretary in another state, because the system is not keying right. Now you are 30 minutes behind schedule, and the next 2 patients who were waiting for you are upset that you are behind. Your patient satisfaction scores are now dropping, and by the way, you did not get reimbursed from Medicare, and this is wrong, and that is wrong.

You are doing all of this by yourself, and now you are done with your day; it is 10:00 at night, you have not eaten lunch, and you are supposed to decide, “OK, what am I going to do that is good for society?”

Instead of the threat of oncologist monopolies, how about taking as much off the plate as possible from these physicians so they are not worrying about negotiating their business contracts and their drug purchasing contracts, and they are not all one at a time dealing with payers, but rather all at once dealing with payers? You are setting up paradigms whereby they can be efficient clinical and business people bringing value to the system.

VBCC: Do you view healthcare as a fundamentally flawed financial system that has lost its ability to keep the practicing oncologist financially viable because of an erratic and unsatisfactory revenue stream?

Dr Pecora: That’s the subtext, but that is not what is driving this for me. What is driving this for me is the fear that we spent 30 years finally figuring out how to treat people effectively, and we are not going to be able to do it because the system implodes on itself.

VBCC: Where are you seeing support for what you are doing, do you see it spreading, and what are the trends? Who is behind this, who is uncertain about it, and who is opposed to it, if anyone?

Dr Pecora: I do not know that anyone is opposed to our efforts, because I am not sure these are fully appreciated for what they are. We are receiving a lot of support from hospitals and from physician groups that are very enamored with the idea of what we have done at RCCA. Even the payers have been so far supportive of it, because they believe this will provide them a conduit to achieve what they want, which is efficient care without wasteful spending. At least, that is what they have told me; so far it has been all good.

VBCC: Purchasers, particularly large employers, are often leading the way toward wellness and the aggressive pursuit of innovation. Do they see the advantage of being proactive instead of reactive about RCCA?

Dr Pecora: Absolutely. Part of what we need to prevent patients from coming back is the interplay between having had cancer and going back to good health, or counseling family members of the patient with cancer as well, so they can, where it is avoidable, avoid it. We, as a profession, have to step up and assume the responsibility of maintaining quality while controlling the cost of care. If we do that successfully, we will be ultimately rewarded in the marketplace. That is why we are very enthusiastic about what we have done, and you are going to be hearing a whole lot more from us, and about us, as time goes on.

VBCC: Is ASCO in support of this, or for that matter, is the government?

Dr Pecora: There is no word yet from ASCO, but it is early. We only came together on January 1, 2012. But we have had very positive praises from the American Cancer Society, and we have had private positive praises from the payers and from the industry.

VBCC: Do you expect this to be growing to other states?

Dr Pecora: We named it “regional” for a reason. We do not intend on staying limited to 1 state. My hope is that we can show a path that makes sense to people and get people excited.

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