“I’ve been treating patients since 1983. I’ve never had a patient come up to me and say, ‘I want to die cost efficiently.’ Never. Not once.” Those were the opening remarks from Andrew L. Pecora, MD, FACP, CPE, chief innovations officer and vice president, cancer services, John Theurer Cancer Center at the Hackensack University Medical Center in Hackensack, New Jersey and president of Regional Cancer Care Associates, during his presentation entitled Translating Evidence-Based Research into Value-Based Decisions in Oncology- Integrated Delivery Networks. This statement made it clear that there is a disconnect between patients and payers.
Adding to the problem, the person in the middle, the physician, is being asked to do more and more. To illustrate, Dr Pecora said that as an administrator in the hospital, he has to ask his doctors to be “really good internists because you are giving people chemotherapy that may cause side effects and you have to assess their medical condition, whether they can get their drugs, have a toxicity, and do all those things. You also have to be an oncologist and understand the drugs and write the orders. You have to be a molecular biologist now because of all the pathways and you have to read about these things and really understand them so that you know you are ordering the relevant test so that you give the right drug and not the wrong one. You have to be an informatics expert because everyone is going into electronic medical records and using pathways. You have to be a social scientist and an economist now since society has now made you responsible for the cost of care of delivery. You have to be an end-of-life specialist. You have to be a pre-certification expert and, by the way, you have to meet all of the quality standards that everyone is promoting—there are about 50 of them now. You have to take time to talk to the patient and be nice to them.”
After going through that list of responsibilities, Dr Pecora ended with, “And by the way, don’t make a single mistake.… And do this in 15 minutes. And do it 30 or 40 times a day.” He asked, “How can any human being do that?” Yet, this is what is being asked of physicians and he is concerned that we are continuing to add to their responsibilities.
Instead, Dr Pecora stated, we need a model that lets physicians be physicians and frees them of some of the administrative duties. We also need a model that embraces the multitude of ways that patients are classified and treated. Conventional models may combine patients bluntly, such as “All breast cancer patients are the same.” Instead, Dr Pecora argued for a system that segregates patients into more realistic diagnostic and prognostic groupings. He believes this will be the key to better outcomes and better ways to measure outcomes. For example, Dr Pecora stated that there are 3 pages of tests for leukemia that allow clinicians to place patients in the correct treatment group. “Once you segregate people and better refine your segregation, you have a group of patients where biologic variability goes down and therefore you can measure, with greater fidelity, the outcome of what you are doing,” he said, and that “The absolute key to this is to track in real time the things that matter,” adding that the 2 things that matter are overall survival and progression-free survival. Those are the outcomes that physicians are selling and the patients are buying (ie, survival). And the product of survival needs to be properly tracked and it needs to be tracked in a manner that frees a physician to do his/her job. That is the reasoning behind Cancer Outcomes Tracking and Analysis (COTA), a point-of-service decision-support tool. It groups patients based on diagnostics and treatment, and tracks them in real time so that the medical staff can make more informed decisions quicker. As a result, the staff has more time to focus on caring for its patients.
Tracking Outcomes That Matter
COTA tracks patients in groups that are applicable and compares each patient’s outcomes with similar patients. The segregation of patients is based on many factors such as histology, stage, genomics, epigenetics, proteonomics, relapse, and resegregation with new information. Furthermore, patient data are tracked daily with a focus on reporting outcomes that matter the most (ie, progression- free survival, overall survival, and cost). Using this setup, outcomes for each patient and each cancer center can be compared with other centers with similar patient populations ().
Dr Pecora stated that COTA, along with its QuantiaMD system, allows physicians to provide (and monitor) point-of-service decision support. He compared the setup to a global positioning system (GPS). The physician knows where they are starting in a patient’s treatment plan and they know the final destination (survival and a reasonable cost). Daily tracking of patients’ cost and outcomes allow physicians to map the progression of treatment. Dr Pecora noted that a good GPS will only make noise if the traveler goes off target. Similarly, a good point-of-service system will remain quiet if the patient is proceeding as planned and red flags will pop up if there is deviation from the target. This can be measured in different ways, but Dr Pecora showed examples in which both outcomes and costs are monitored to allow all parties to know how the patient is progressing compared with similar patients ().
Dr Pecora concluded his presentation by cautioning the audience: “We do not want to be in a setting where we are creating that moral double jeopardy for our physicians and nurses where they have to decide between ‘I think this is best’ and ‘I don’t know if they can afford it.’ We don’t need to go there.” But he said he remains optimistic, adding: “I think you will see solutions come into the marketplace that heretofore were not even considered in medicine and I think one of them is that we will move from selling services to selling products. And by selling products you are accountable for the 2 things that matter—the outcome and the cost.”