Viewpoint

Meet Joe, the New Face of Cancer

He has other serious health problems and needs a clinician to quarterback the care for all his conditions—not just the cancer.

Zachary Hafner
Advisory Board

The NIH estimates that somewhere between $150 billion and $200 billion will be spent annually on cancer care in the United States by 2020. No doubt, the rising costs of cancer treatment drugs make managing oncology expenditures a steep hill to climb. But despite all the attention that their six-figure price tags have gotten, cancer drugs aren’t the only culprit and are just part of the story.

Zachary Hafner

According to an analysis of Medicare data, 40% of cancer patients have one or more comorbidities and 15% have two or more, the most common of which are diabetes, chronic obstructive pulmonary disease, and congestive heart failure. Many people with these chronic diseases are able to manage them well with routine care so that drug therapy, nutrition, and other important factors are well monitored and nothing “falls through the cracks.” But for cancer patients with comorbidities, the cracks tend to get bigger and also harder to see. Diseases like heart disease or diabetes can complicate cancer care on multiple levels—and vice versa. And, ultimately, that can lead to huge expenditures, expensive interventions, and poor outcomes for patients. Here’s an example, a composite of what can happen: Joe has congestive heart failure and is seen regularly by his cardiologist, who helps him manage the condition with medications. Joe does his part by changing his diet, exercising regularly, and taking his pills as directed. On the whole, he is living well with congestive heart failure and can work full time and spend quality time with loved ones. But then Joe finds out he has late-stage lung cancer. Oncologists, pulmonologists, thoracic surgeons—he has appointments with them all. He has little mind share left for CHF.

Joe slacks on his diet and exercise and doesn’t take his meds on days when he’s feeling too tired or sick from chemo. He gains weight quickly and frequently experiences shortness of breath, telling signs of worsening congestive heart failure but also common side effects of cancer treatment. Joe has to stop working when the swelling in his legs gets too painful and makes it hard to walk. He eventually has a set of acute episodes that leave him hospitalized. In the hospital, Joe learns that his heart failure has advanced quickly and he is no longer a candidate for chemotherapy.

Lung cancer is a serious diagnosis. It requires top-notch care and aggressive treatment. But so is congestive heart failure. Even though Joe could live well with the disease while it was managed correctly, it has seriously affected his quality of life with cancer. As it has progressed, his heart failure has also become much more expensive. Each stay in the hospital, for instance, costs upward of $10,000—and one day in the ICU can cost $10,000 per day.

So what can we do for patients like Joe? We need to integrate care, which in this context means bringing together the care for cancer with the care for all the other health problems that patients might have. Cancer programs famously form interdisciplinary teams of medical oncologists, surgical oncologists, and radiation oncologists to treat cancer—but just cancer. Other conditions and the specialists with the expertise to treat them are not included. That needs to change.

Here are four suggestions for how cancer care for people with comorbid conditions could be better managed:

  • Assign a care “quarterback” and integrate the care plan across all providers (inside and outside of oncology) so that one person is directing the care experience starting at diagnosis. Primary care physicians make great quarterbacks.
  • Embed the quarterback in the cancer care team (and if your program is large enough, also include cardiologists or an endocrinologist) and routinely address noncancer care needs in the same office visit at which a patient is seeing a medical oncologist. (Pro tip: If your contracts are fee-for-service, then you’ll need to bill for them separately, including different diagnoses for the two visits.)
  • Bake in palliative care seamlessly, so that all providers on the team—and patients and families themselves—are aware of the goals, resources, and benefits of palliative care and are explicitly aware of the patient’s goals for treatment, pain management, and quality of life.
  • Round out the care team with care managers and behavioral health services, including psychosocial screenings, to be sure that factors that are often overlooked like depression and family dynamics aren’t getting in the way of care.

If you think this sounds unrealistic, then you might have a point. This level of coordination will take work and a ton of cooperation among providers. And in many markets, the financial incentives still perversely reward uncoordinated care.

Figure:
The new Oncology Care Model by the Center for Medicare & Medicaid Innovation puts oncologists on the hook for care that’s traditionally been considered outside their scope.

Practices are accountable for total costs of care under CMMI’s Oncology Care Model

* PBPM=Per beneficiary per month.

Source: Advisory Board, 2016

But you have to consider where health care is headed and shift toward population health management. CMMI’s new Oncology Care Model, for example, is nudging providers toward performance-based payment based on total cost of care (including care for nonrelated accidents and comorbidities). We’re already moving toward a more holistic approach, with accountability for cost explicitly shared across a broader team of providers. That is an important development. There are millions of Joes out there. And with an aging, sicker, population on the horizon, Joe may just be the new face of cancer.

Zachary Hafner leads Advisory Board’s strategy consulting practice.