Treating cancer • Project: Question routine, reduce waste, but don't be cheap.
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It's the new managed care motto: cheaper care is better care.
But a trio of studies by researchers at Intermountain Healthcare often cited as a model of efficiency and cost control shows it's more complicated than that.
"Everyone is running around and saying value equals quality divided by cost," said John C. Ruckdeschel, medical director of Intermountain's Oncology clinical program. "But if you accept cost as the denominator, you would always assume doing the cheaper thing is better, and that's not always true."
A decade ago, Ruckdeschel and his colleagues set out to improve cancer care at Intermountain's 23 hospitals. Their goal: root out waste, or tests and treatments of questionable value to patients.
This included reviewing scientific literature and developing standards of care for doctors to follow, measuring compliance with those standards and tracking outcomes.
"It sounds simple, but it's really very difficult," said Ruckdeschel, who shared results from the experiment this winter at the American Society of Clinical Oncology's first Quality Care Symposium.
Some charted improvements were money-savers.
Fewer breast cancer patients had a breast removed: 58 percent of women had a mastectomy in 1998, compared with 25 percent of women 10 years later.
Also, fewer women had invasive surgery to remove all lymph nodes under the arm, and instead had just one or two "sentinel" nodes examined to see if cancer had spread. Sentinel nodes are the first few nodes into which a tumor drains. Before the project began, about seven out of 10 women had sentinel node biopsies; after, the number rose to almost nine in 10.
But Intermountain also convinced radiologists to more promptly order positron emission tomography, or PET, scans on lung cancer patients to determine if they're candidates for surgery.
PET scans are more expensive, but less error prone than the commonly used CT scan, explained Ruckdeschel.
"There is no reason why one hospital should be doing PET scans 80 percent of the time and another hospital doing it 30 percent of the time," he said. "Sometimes it's more important to do one expensive test first than to build up four or five cheaper tests."
The challenge of accountability. • Showcasing these findings was a tactical decision by Intermountain to promote its cancer program, which competes with the University of Utah's Huntsman Cancer Institute.
"We're not going to duke it out with Huntsman over the latest [cancer gene discovery]. We don't do basic lab research," said Ruckdeschel.
But Intermountain is uniquely equipped with the technology to use science and data to drive the right treatment to the right patient at the right time, he said.
Hospitals "can't just go paperless," Ruckdeschel explained. "The data needs to be searchable and it needs to merge with other data, such as patient lab results and medications. And you need to be able to follow patients over a period of time."
He adds: "Unless you can do this kind of analysis, following complex diseases over time, you're going to have a hell of a time becoming an accountable care organization," the reform model based on paying providers for quality care.
The findings, however, also highlight how hard it is to do right.
"If hospitals equate better with cheaper all the time, they're going to make a lot of mistakes and fall into the trap that HMOs fell into in the early 90s," warns Ruckdeschel.
Health centers everywhere are under pressure to reduce waste.
America's medical system squanders .30 cents of every dollar spent on health care, according to recent estimates by the Institute of Medicine. That's $750 billion spent on treatments that don't help, and sometimes harm, patients; injuries from unsafe care; needless paperwork and fraud.
Complex, expensive-to-treat diseases like cancer are a big part of the problem.
"If I'm a primary care doctor and you come to me with a bad cold and yellow phlegm, I'm going to decide if I'm a Z-Pak prescribing doctor or if I'm the kind to prescribe rest and fluids," said Ruckdeschel.
"But when caring for a complex disease like cancer all the pieces fit together. It's not a question of how you do the radiation, how you do the surgery or how you do the chemotherapy. It's a question of whether they should be done, and in what order they should be done."
Teaming up. • While standards for treating cancer exist, Ruckdeschel's team discovered wide variation in doctors' adherence to them.
"Sometimes it's a matter of local preference, or doctors being trained at different times and working in isolation," he said.
In the project, doctors retained discretion over patient care, but were trained on the policies. "When we confront them with the data," he said, "they usually change."
Doctors have to buy into the standards, he added. "When you have an insurance company or administrator coming in and telling you what to do, that is not the formula for success."
Feedback from peers is more convincing. One convenient way "to get colleagues in a room where the rest of the players have egos and credentials the same size" is to convene a "tumor board."
It's still dark outside when a group of breast cancer specialists assemble for a tumor board meeting at Intermountain Medical Center.
Each week, a dozen or so providers nurses, pathologists, radiologists, surgeons and oncologists meet to gather consensus on the best care plan for patients.
"The path is not always clear cut," said William Rees, surgical director of the Breast Clinical Program, noting how standards of care can be muddied by a patient's age, tumor type and size or her personal wishes. "And each specialist brings to the table his or her biases and expertise."
They mull questions like whether to recommend genetic screening for patients whose insurance plans won't cover it. They talk about the risks of surgically removing advanced tumors in the frail and elderly.
Should they prescribe chemotherapy before operating or after?
Most often the group comes to a consensus. But about 10 percent of the time, there's a legitimate difference of opinion about how to proceed, in which case providers review options with the patient at a special multidisciplinary clinic, said Rees.
Tumor boards have been around for decades and there's mixed evidence of their value. But Intermountain patients give it high marks.
"Over three to four hours I was able to meet with everyone, a nutritionist, geneticist, radiologist, patient navigator, surgeon and oncologist," said 38-year-old Cerise Nichol, who was diagnosed with stage 3 breast cancer in November.
"It was nice to have a clear strategy," she said. "There was no way I could make sense of all the conflicting research. I didn't know what to think, other than, I'm too young for this."