What Says Nostradamus?

If Nostradamus knew the far-reaching complexities of cancer care delivery, he probably would have allowed his mind and spirit to wonder about the future of oncology centuries later. Well, there was no oncology in those days. Health and disease were the work of the devil and evil spirits. Nonetheless, some educated guessing - although it falls short of prophecy - can be made based on history, geopolitics, U.S. culture, and human psyche.

Well, here are my prophecies about cancer care and the future of community oncology. But, before going there, it is critical to mention that the political landscape of the U.S. in the coming decade will have far-reaching consequences on cancer and other health-related services. Although we credit political contributions and the lobby power of organized medicine for the gradual shift of cancer care from the community to hospitals and large institutions, the fact is, large healthcare advocacy organizations and academic centers poured money into the campaigns of the politicians who share their philosophy and beliefs. Certainly, this is empowering them to push forward with their agendas.

It would have been a waste for these organizations to spend such monies on politicians and candidates who advocate local control and state’s rights. Those politicians are in the camp that philosophically supports community oncology. Many of them are crusaders for our cause, despite the mediocre financial support they are getting from community oncology advocacy groups. That is tragic. The damage could have been minimized or even avoided if community oncologists were better self-advocates than they seem to be. Centralized healthcare, including cancer care delivery advocates, had a free ride in the absence of effective counter advocacy groups.

Our deafening absence from the scene has allowed obscenity to become the normal, acceptable alternative to a sensible, common sense philosophy. Otherwise, how can we explain the continued push for the exodus of community oncologists to hospital employment despite the evidence showing community oncology provides less expensive, more convenient, and equally effective cancer care? We know it, experts attest to it, and well-versed policy makers seem to ignore this fact because of the powerful lobby that guides their decisions.

Centralized health care advocates claim/hope or assume that the exodus of community oncologists and other physicians from private practice, albeit costly initially, will save money with time. They assume that future bundle payments contracted with large institutions that can provide A to Z care will cut costs, but we all know the contrary is more true. Unfortunately, what is obvious to most of us will only become a reality in the eyes of policymakers several years from now.

We have only two potential scenarios where this destructive trend is hampered: first, if we, community oncologists and other physicians, change gears and get more involved in politics and advocacy. That doesn’t seem to be happening any time soon.

The second and more hopeful scenario – although it seems to be unlikely to happen – is that we elect officials who actually care about the health of our healthcare system and its solvency. If we were fortunate to elect large numbers of such politicians, their first step would be to pass legislation that rewards the delivery of high value, patient-centered care.

Prophetically, I am pessimistic about a favorable change, at least in the government-run programs. It is hard to imagine a significant reversal of the trend in the current political environment.

There is light at the end of the tunnel, and we have seen it bright and clear. Employers, sick and tired of the rising cost of healthcare, are no longer sitting on the sidelines, watching as their money is wasted. They are realizing that no one other than them cares about their bottom line. They are taking charge.

First, employers have concluded that insurance carriers are not invested in cost savings. Insurance companies work on margin. The higher the healthcare cost, the better the revenues.

Self-insurance is appealing and employers are realizing this. It is replacing traditional insurance gradually with an annual growth rate of 15 percent or more. In fact, even smaller employers, 100 or fewer employees, are finding this to be a cost-effective money saving strategy. At the least, they are saving the margin normally cashed by the insurance companies.

However, it doesn’t stop there. Many employers are opening workplace clinics. We run such businesses in our region, and there are hundreds of such clinics nationwide with remarkable cost savings. This system, when collaborated with the third party administrators as we do, can have farreaching positive consequences in trapping overutilization and irresponsible costly medical care. An unintended consequence of the workplace clinics is pressuring insurance companies to be more cost conscious, that is, if they want to keep their customer base. In fact, some insurance carriers are implementing some healthy plans, such as:

  • Steering patients to more cost-effective centers for imaging, which is appealing to patients, especially those who have tangible out-of-pocket expenses. It is happening now on a limited scale, but I expect it to grow in the future.

  • Terminating contracts with some providers based on cost and quality of care. We are seeing it happen, at least in Ohio. I am sure this will become a widespread policy, with or without legal repercussions. This is only the beginning. I think the day when any physician can be a provider on a plan, if he wishes, is soon to go. Profiling is coming. It is inevitable.

  • Using the plan’s own clinical pathways. Following those guidelines is incentivized by preauthorization, waiver, and in some cases, financial incentives. Insurance companies, under pressure to contain costs, have concluded that pathways established by the providers and organized medicine are infested with conflict of interest and pushed from the pharmaceutical industry. They are taking charge and rightly so. I predict that this trend will grow fast in the coming years. There will be push back against such policies based on quality concerns. I doubt that will work because it is becoming obvious that more money spent does not necessarily translate in to better outcomes. The evidence points to the contrary.

Very large employers, such as Walmart and Lowes, have established centers of excellence for heart and spine surgery where they fly their patients and a companion to the centers all expenses paid. They still save money and receive a proven superior quality of care. This is the beginning. Programs that are more robust are to come. Patients still can choose a local provider, but they have to pay their co-pay share per policy.

In the book I published five years ago, “Good Medicine is Cheaper Medicine,” I concluded that the only way we can improve quality and contain costs is through individual responsibility. That can come through monitoring out-ofpocket expenses by patients, and more dramatically, it is coming through the employers taking charge of their health plans. The latter seems to be shaping up as the holy grail of medicine.

My final prediction has to do with the big gorilla in the room: the Affordable Care Act (ACA.) When I wrote my book, I did not address ACA because it wasn’t conceived yet. Now it is borne but with major physical and mental disabilities. Employers were concerned about the impact of ACA, they were frozen not knowing how to proceed, not knowing how it will play. Now there is ease. Either it is going to be dismantled or - to save face - it will be drastically modified. I believe the November 2014 election results will have critical consequences on how the government will proceed. One thing is clear: it is going to be more costly to the taxpayers and to the employers. The taxpayers are at the mercy of the policymakers, but the employers can read the crystal ball. The penalties will rise and drastically so. Hence, they are proceeding with their own reform, the American way, by taking charge of your own affairs and letting the government do what it does best: waste our money

Kelsey Knutty