How do we address the crisis in cancer care? Start by changing the ‘culture of medicine’


Bruce Feinberg, DO

Vice President
Chief Medical Officer
Cardinal Health Specialty Solutions

Bruce Feinberg, D.O., vice president and chief medical officer for Cardinal Health Specialty Solutions, will give a presentation at The American Journal of Managed Care conference on “Patient-Centered Oncology Care” in Baltimore on November 15, 2013. Feinberg has more than 25 years of cancer-care experience, the majority as a community oncologist.

Q: Give us a sneak preview of what you’ll be discussing at the AJMC conference.?

A: What’s on everyone’s mind these days is the Affordable Care Act and healthcare reform. Nowhere is the need for reform greater than in cancer care. The recent Institute of Medicine report described the cancer care system as in crisis. I agree. We’ve got an aging population – and cancer is a disease of aging – and rising costs that are increasing partly because of our success in helping people live longer and partly because of the high cost of innovation.

Q: What are some strategies that can help solve this cancer care crisis?

A: The pundits and policy wonks typically boil it down to four things:

  • Paying for value, not volume.
  • Ensuring providers develop core competency in using evidence-based care.
  • Delivering patient-centered care –that is, getting patients involved.
  • Improving health information technology to enable these three things to happen.

All of these ideas are grounded in certain suppositions: that we can define value and pay for it; that physicians lack core competency in practicing evidence-based care; that patients are truly able to share in decision making given the complexity involved. These are big suppositions. But more importantly, I think we should all be asking, "will these interventions change behavior and reduce costs?"

I hope to prove in my presentation, with data, that these suppositions, albeit logical and supported by case study, do not hold true at the macroeconomic level. There is a separate driving force – the culture of medicine – that must be addressed to successfully reform cancer care. The current culture of our medicine for both physician and patient can be encapsulated relatively simply: It embraces now over later, new over old, and more over less.

Q: What’s Cardinal Health doing to change that? Can you really limit costs and improve outcomes at the same time?

A: The idea of “pathways” is increasingly accepted as a way to improve patient care while bending the cost curve. Pathways are basically sophisticated checklists that can be used in real time to reduce variations in treatment and improve patient outcomes by increasing the use of evidence-based medicine.

Our program is called Clinical Pathways and our software product that supports it is called Pathware. Most pathways providers espouse a similar philosophy. We’re all focused on reducing variance in ways that control costs and improve outcomes.

Q: So what’s different? How does Cardinal Health’s approach differ from others?

A: We’re different in a couple of ways. First, we use a consensus-based approach to pathways design. Our Clinical Pathways are developed by steering committees comprised of the physicians who will use them. This helps drive physician buy-in, and allows us to ensure each set of pathways meets unique needs or regional differences in how cancer care is delivered.

Second, we’re more clearly targeting low hanging fruit. We’re not trying to be the pathway solution for every cancer in every situation. To truly bend the cost curve, you’ve got to directly engage both patients and physicians. This is very resource intensive and needs focus to succeed.

Rather than try to do everything, we focus on the 80% of cancer spend – predominantly the treatment of breast, lung and colon cancers. To get results and buy-in, you need to aim at the low-hanging fruit. An active physician engagement process needs to focus on three areas of care for three cancers, not 100 items applied across every disease.

Q: What role does health information technology play?

A: The first generation of pathways didn’t have a perfect software solution. Claims data would monitor activity, but that was always three to six months, after the fact.

Today, technology transmits knowledge instantly. Our <Pathware< Link: Internal:>> tool provides real-time information immediately on a PDA, laptop or desktop. It’s hardware agnostic. Physicians can sort and analyze real-time data on all patients in the HIPPA-compliant system. That lets them understand their treatment patterns better or compare themselves to others.

Our technology helps doctors stay up to date with new medical evidence, so a new black box warning on a drug will show up that day while a new treatment will get put on the agenda for the next steering committee meeting. Our goal is for Clinical Pathways and Pathware to manage information in ways that make it easier – almost automatic – for physicians to deliver cost effective, evidence-based cancer care.

Q: Does it work?

A: Yes. The payors we work with set a high bar for compliance – requiring participating physicians in their networks to comply with the Clinical Pathways they develop, at least 80 percent of the time. All of our Clinical Pathways programs exceed that goal, averaging compliance more than 90 percent of the time.

We also have solid peer-reviewed and independently validated data that supports the effectiveness of pathways, in achieving the elusive goals of better patient outcomes and lower cost but not at the cost of the physician. I’ll present some of that at the AJMC conference.