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What Dana-Farber's Shakeup Means for Cancer Care · CareTalk: Healthcare. Unfiltered.

• 0:00
  The Dana-Farber Cancer Institute rocked the cancer world this month by dropping its longstanding partner.
• 0:06
  Harvard Medical School affiliated Brigham and Women's Hospital in favor of building a new cancer hospital with Beth Israel Deaconess Medical Center, also a Harvard Medical School affiliate.
• 0:16
  Well, what does it all mean for patients, physicians, and healthcare costs?
• 0:21
  And is this just a local Boston story, or is there broader meaning for the U.
• 0:25
  S.
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  healthcare system?
• 0:34
  Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
• 0:39
  I'm David Williams, president of Health Business Group.
• 0:42
  And I'm John Driscoll, the president of Walgreens Health.
• 0:44
  So David, is this just a Boston story about two hospital and Harvard affiliates duking it out for real estate, or is there something more here?
• 0:56
  Well, I mean, I think it is, yes, a Boston story for sure, but you know, among stalwarts in the industry, I think everybody's heard of Dana-Farber, Mass General, many have heard of Beth Israel and Harvard as well.
• 1:07
  So it's very much a Boston story, but it's not unique to Boston.
• 1:10
  There are other places around the country where you see the top medical centers, Mount Sinai and New York, Stanford in California and University of Texas, MD Anderson, also building dedicated cancer hospitals, John.
• 1:23
  So there's a bit of a trend, even though a lot of other parts of healthcare are going more toward outpatients.
• 1:28
  So it's not just Boston.
• 1:29
  Well, I actually think you're I think that the 2 things that are happening that are relevant to folks, I think, are continuing consolidation of hospitals as they look to sort of become master contractors and control their own destiny, particularly at a time when their margins are being.
• 1:50
  stressed and you know, they're fighting it out with managed care companies.
• 1:54
  The other kind of interesting theme from my perspective is focused cancer hospitals, because I think they're the, one of the things that, that, that was true of hospitals in the last generation is they wanted to be a place where they did everything from orthopedic surgeries to cardiac surgery to uh, cardiac care to cancer care and cancer surgery.
• 2:18
  And this notion of a focused factory is it is really had some success at places like City of Hope, M.
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  D.
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  Anderson, Memorial Stone Kettering.
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  And if you look at the top National Cancer Institute ranked cancer institutions, you know, the places that are getting the most They're sort of the top of the top because you can get cancer care everywhere.
• 2:40
  It is a, it is disproportionately, although not exclusively, uh, represented by, by cancer focused hospitals.
• 2:48
  Even though there are some great institutions like the Harvard affiliates, MGH, Mass General Hospital, Johns Hopkins in Baltimore, um.
• 2:57
  That are that are that are also showing up on that list and so I think that I guess I'd unpack it and say should we be as consumers and as potential patients since cancer is still I think the second largest killer in the United States after cardiac should we be worried about?
• 3:14
  Hospital consolidation from a patient perspective, John, we're going to have a chance to see both of those models play out here in Boston.
• 3:22
  A lot of the places you're talking about are dominated by one system or another.
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  Now, M.
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  G.
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  H.
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  Even in the name is Massachusetts General Hospital.
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  They are going to be taking the approach where you're within a general hospital and you've got a cancer center.
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  And that is also what It's different from what's going to happen with Beth Israel and Dana-Farber, where they're going to have, uh, they're going to have a particular focus on cancer.
• 3:43
  Now the argument to have, uh, the, the broader one is that patients with cancer, they don't just have cancer.
• 3:50
  And also that the complications, uh, arising from cancer or the, the treatments, uh, causing certain side effects are going to affect things and you're going to need cardiologists.
• 4:00
  Nephrologist and so on, even if they're not specifically focused on oncology.
• 4:04
  Now the truth is, John, right now Dana-Farber is connected by a bridge, a sky bridge over to Brigham and this new hospital is just going to be down the street.
• 4:13
  So we're not talking about being, you know, that far apart.
• 4:15
  I don't know how much difference it actually makes, uh, in practice.
• 4:20
  And I also am not sure if I agree with the focus factory model.
• 4:23
  I see that more for things like.
• 4:25
  Uh, hip transplants are things that are really sort of a cookie cutter, and those can be focused.
• 4:30
  Whereas general hospital and even cancer, it's pretty complicated and each patient varies a lot.
• 4:36
  So that's, that's, I think it's really the, the, the jury's out on whether, and cause there are clearly examples in, uh, In the top cancer institutions in terms of like the top cancer institution in the United States, you know, have the NCI have a higher survival rate and it's a mix to your point of general hospitals and focused cancer hospitals.
• 5:00
  The next question from a patient perspective, if you're okay, because you're just switching the title and playing around with the ownership, is Doesn't hospital consolidation typically lead to higher prices?
• 5:12
  Yeah, it does.
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  And here too, we'll have to see because there's some counterbalancing forces.
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  So in this case, what's happening is the biggest and strongest hospital system in Boston, which is formerly known as Partners, now Mass General Brigham.
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  They're losing out to more of the upstart, which is Beth Israel, Leahy, which is also pretty big and is getting bigger.
• 5:31
  So what you're having is actually less consolidation, uh, and more head to head competition.
• 5:36
  Now, so there's less consolidation.
• 5:38
  On the other hand, you could also say.
• 5:41
  Well, you're going to have more spending, right?
• 5:43
  Because there's going to be a bit of an arms race, which is ultimately going to cost folks.
• 5:46
  The Mass General Hospital, I'm told, is already ramping up its advertising.
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  They're going to be investing.
• 5:52
  Uh, and then you're going to have this new entity that's investing.
• 5:54
  So there's a concern about just like how much money is being put in and who's going to recoup it.
• 5:59
  And so, David, how's, who ends up paying that bill?
• 6:06
  Well, hopefully somebody in Washington as opposed to in Boston.
• 6:09
  Well, that's everybody though.
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  I mean, I, I, I guess, I guess the question is, Can, can these, I thought the attorneys general were going around, I mean, one of the biggest challenges in the U.
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  S.
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  health care is increased costs.
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  The biggest chunk of cost in the U.
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  S.
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  health care system is hospital systems.
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  There's been a ton of research that says hospital consolidation, when two hospitals combine, one buys another where they merge, that costs typically go up.
• 6:36
  I mean, are the attorneys general and the hospital rating authorities just asleep at the switch here?
• 6:42
  Like what's.
• 6:43
  Yeah, well, I mean, what, what, as a, as a, as a patient, it doesn't sound like we should be worried as, as, as, as with, as a, as a family that's got some members with folks who are fighting or cancer survivors.
• 6:57
  So I'm not worried about my mom or my, my other relatives who've had cancer.
• 7:02
  That's great.
• 7:03
  But aren't they all, aren't we all going to be paying a higher price?
• 7:07
  John, I think this is where we have to talk about value based care and if we believe it and where it's going.
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  So, uh, we actually have seen a tailing off of spend per Medicare.
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  recipient over the last few years.
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  Largely, we could argue because of Medicare Advantage and focus on on value based care there.
• 7:24
  And there's an unpack that.
• 7:26
  I mean, do you want to maybe tell people share with people the trend of Medicare cost shift?
• 7:34
  increases.
• 7:35
  Um, and what's happened over the last five years.
• 7:38
  If you look at we've had these conversations for a while, john, if you looked at the trajectory of where Medicare spending was going, it's basically Medicare is going to bankrupt the whole country.
• 7:46
  And though we've had debates about things like Uh, the pandemic, uh, expenditures and the huge tax cuts, Medicare is actually a bigger driver, and there's been, you know, like, trillions of dollars that are cut off of what we expect to end up paying over the next 15 or 20 years because the increase of cost per Medicare recipient has, has very much flattened out, uh, over the past few years, and it's a trend people haven't necessarily noticed that much, so my point, John, is that If you have Obama, if that's right, if you have two competing hospital systems in the olden days, you'd say, hey, they're going to spend more.
• 8:26
  They're going to bring more people in and so on.
• 8:28
  Now, if they actually have kind of care on a budget and you're and they're being actually rewarded based on outcomes, you have a possibility that the 1 that is actually.
• 8:39
  More efficient and better wins more patients without driving up costs.
• 8:43
  That's the vision.
• 8:44
  I think it's possible.
• 8:46
  Yeah, I think you're delusional, David.
• 8:49
  It's not the first time.
• 8:50
  Uh, so let's talk about how we should measure.
• 8:55
  Whether we're winning or losing the war on cancer and then tie that back because we, we, uh, I think your buddy, President Nixon, your, your, your, your, your model, uh, President, President Nixon, I believe, was the first person to declare a war on cancer.
• 9:12
  Um, and, and, and in many ways we are winning a little bit like Ukraine grinding it out by the yard.
• 9:20
  And then you have Biden.
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  to bookend it with his cancer moonshot.
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  Can you talk a little bit about cancer trends and what people should be thinking about?
• 9:29
  And then let's talk about perhaps how we can measure the success of this from a, from a treatment, care, and incidence perspective.
• 9:37
  But what are the cancer care trends?
• 9:39
  And, and, and, and I, I think based on the numbers I've been looking at, we've been actually doing pretty well.
• 9:45
  So John, uh, you mentioned early on in the podcast that, uh, cancer is the number two cause of death, and it is.
• 9:51
  Um, that's actually been the case since the 1930s.
• 9:54
  So it's heart disease is number one and then cancer is number two.
• 9:56
  Not all, not all of us are that old, but thanks for bringing it up.
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  Some are, uh, but including some people, you know, who are around, uh, today.
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  If they're in their 80s, they were, they were around at that time.
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  And so there's.
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  There's a lot of cases, about 2 million cases a year and about 600, 000 deaths.
• 10:12
  However, uh, the death rate has declined by about a third since 1991.
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  And it's been, it's been grindingly consistent.
• 10:22
  So although people may not realize it, we actually are making pretty dramatic, you know, to, to, to talk about breaking the back of the cost curve.
• 10:30
  That's pretty impressive, right, David?
• 10:32
  Well, in terms of the incidents.
• 10:34
  Now, the cost has gone up because there is more.
• 10:37
  I mean, so the overall cost of society has gone down, right?
• 10:39
  Because more people are alive.
• 10:41
  Uh, so that's very good.
• 10:42
  Um, therapies are expensive.
• 10:44
  It's like 4, 4, 4, 4 million lives that we either, 3.
• 10:46
  8 million, I think, is that we would have lost if we hadn't cut the cancer death rate consistently since 1991.
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  So this is where when we talk about the U.
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  S.
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  healthcare system not getting what we pay for.
• 10:59
  And cancer, arguably, is.
• 11:02
  An exception or even the exception to say, yeah, this is why we have an expensive healthcare system to reduce deaths, suffering from cancer.
• 11:10
  Uh, so, so we have that happening now, there's some concern about what's going on.
• 11:15
  And there have been more like anecdotal information for the most part about younger people getting cancer and getting more aggressive forms of cancer.
• 11:22
  I think the statistics, long term statistics haven't played out yet there.
• 11:26
  Well, I disagree, David.
• 11:27
  I think you see a modest increase in pediatric cancer pretty consistently, and the incidence of cancer is still relatively high.
• 11:35
  We're just getting better at healing, managing, and turning it into more of a chronic, not in every area, but chronic condition.
• 11:42
  Um, you know, I, I, I, I do worry about that, but, you know, unpack some of those statistics and maybe talk a little bit about some of the health equity concerns as well.
• 11:53
  Sure.
• 11:53
  So I think the biggest driver why we will have more cancer cases is that the population is aging and still the single biggest predictor about whether you're getting cancer or not is how old you are.
• 12:04
  And so there will be an increase in the number of cancer patients, even if the incidence by age drops off.
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  Now, in terms of disparities, there's very significant racial disparities in particular.
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  And so if someone doesn't have access.
• 12:19
  to primary care, screening, and so on, what happens is when they arrive at, let's say, Dana-Farber, where they'll still have access probably from, you know, due to Medicaid or just that's where people will, will, will be taken, their cancer may be at a later stage, more aggressive and say, gee, you know, if I'd seen this a year ago, we could have treated it and now we can't.
• 12:41
  So those disparities are less in incidence, but in outcomes very much because of the early detection.
• 12:47
  Um, and treatment and just also, you know, getting cancer care is inconvenient.
• 12:53
  Uh, you know, sure, you can put everything aside, but not if you can't afford not to not to work people with cancer.
• 12:58
  Actually, believe it or not, don't pursue all their treatments.
• 13:01
  They still have to make tradeoffs between putting food on the table and getting treatment.
• 13:05
  And so there are economic and racial disparities, and you're seeing it particularly in the success rate.
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  In curing and managing prostate cancer for people who are not of color and the increasing incidence and death rate, which is not changing.
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  And in fact, this is increasing as a difference between, um, uh, white and nonwhite populations.
• 13:26
  I think that's a, that's a, that number is terrible.
• 13:29
  The other interesting number that I saw is that, you know, that, that cancer still is a, in many ways, a bigger challenge for women.
• 13:38
  Based on incidence than men.
• 13:40
  Incidence is going down for older men and up for, and up for women.
• 13:45
  What's going on there, David?
• 13:47
  Well, I mean, there's a couple things, um, and the news isn't quite as bad, uh, as, as those recent statistics would suggest.
• 13:53
  So one reason that cancer has gone up for women is that women in the last generation have started acting more like men, uh, more drinking, more smoking, uh, and so on.
• 14:03
  So you see some of that happening.
• 14:05
  Um, but one thing that has happened too is that, you know, you don't normally think of vaccines for cancer.
• 14:10
  But the HPV vaccine, which has now come out, is that, you know, women in their 20s, who is the first generation that actually got the HPV vaccine from the start, they have a much lower incidence of cervical cancer.
• 14:22
  Now, cervical cancer isn't high in people in their 20s in general, but as a precursor, you know, we may see some of these preventive activities, uh, really have a long term impact.
• 14:31
  I think you've seen the death rate go down by over 30%.
• 14:33
  I mean, it's, it's, it's actually, while it's not as commonly.
• 14:37
  Um, uh, used as it as you'd hope, because it really does work.
• 14:42
  The death rates gone down dramatically.
• 14:44
  I mean, can you And maybe talk a little bit about some of the other things that are, that are, um, that are exciting about cancer care in terms of either curing cancer, which is sort of a shocker for managing it.
• 14:57
  And then talk about maybe how, and then we can maybe get into how this all plays out given the merger.
• 15:02
  Yeah.
• 15:03
  Whether it even does.
• 15:05
  Yes.
• 15:05
  So we've, we generally talk on this podcast about care moving, you know, from high acuity settings to lower acuity settings in particular.
• 15:14
  The home and now we're talking about, you know, which type of hospital is better for cancer, A focused one or uh, one that's within a general hospital.
• 15:20
  That's not normally our discussion.
• 15:22
  And so one of the key questions is, Whether these trends toward the home, whether those play out for cancer or not now, to some extent, they do when you talk about becoming more chronic.
• 15:33
  We have things like infusions, maybe in chemotherapy at home, but there's some other therapies like CART therapies, uh, immunotherapy that, uh, and some complicated surgical procedures that actually really have to happen in a hospital.
• 15:47
  So some of the more complicated and advanced Next.
• 15:52
  changes in health care.
• 15:54
  Some of the things that are that are bringing us forward are expensive and they actually occur in an acute environment.
• 16:00
  In fact, at the Brigham, something like 40 or 45 percent of their surgery volume is for cancer.
• 16:07
  So you think about surgery that I wouldn't have guessed that it would be that high.
• 16:12
  But a lot of the cancer treatments that are advanced are actually things that you do in an acute care.
• 16:17
  Setting.
• 16:18
  So I think that's affecting the approach here.
• 16:20
  I think that's it's almost a bimodal distribution.
• 16:24
  David, you're seeing some targeted surgeries getting better, whether it's breast or prostate.
• 16:31
  In others, but I think that I still think you're the long term shift of care, particularly as you think about, um, the cocktails of drugs, the targeted therapies, the immunotherapies, I think you're going to see a lot more of this being done for short, shorter periods in hospitals and a lot more.
• 16:51
  In outpatient and managed in the, in the, in a home setting outpatient, meaning it could be a satellite facility that you visit daily for your infusion or weekly, depending on the cocktail that you need to take.
• 17:03
  And certainly in the case of Memorial Sloan Kettering, they've, they built a large group of satellites because they believe that in future, 80 percent of all cancer care is going to be in the community.
• 17:12
  It does, but it doesn't mean you're not connected to a hospital, but it does mean that.
• 17:16
  Um, that you're getting care in a, in a, in a better, in a, in a more reasonable setting.
• 17:21
  And, and the more one can shift care out of the hospital, I mean, it's a material reduction in costs in terms of ongoing, even, even infusions.
• 17:30
  I guess, I guess the question, David, is given that, given the.
• 17:34
  the health equity concerns, the increased likelihood of survival and success of cancer care, um, and the fact that we are changing the cost curve.
• 17:44
  How do you, how does that tie out to this consolidation or basically hospital consolidation for cancer care?
• 17:52
  Like what, what, what, what, what matters to the patient and the policymaker?
• 17:57
  I think that it's not correct to characterize this as a consolidation.
• 18:01
  For one thing, we've got, uh, you know, a strong entity moving from the biggest player to the second player.
• 18:06
  So it's, it's more like Hertz and Avis.
• 18:08
  It's actually helping them to catch up and it's actually not a merger.
• 18:11
  Dana-Farber is staying.
• 18:12
  uh, independent and has its own board and fundraising and so on.
• 18:15
  I think we have the opportunity, John, for more accountability in this type of environment.
• 18:20
  We talk about most of, uh, people with cancer are older and, uh, Medicare, uh, hopefully, you know, will, will be something where there's actually fewer disparities.
• 18:29
  It's not based on, uh, you know, it's not based on do you work at a company with good insurance or not.
• 18:35
  And I think there is an opportunity as a society to actually hold these healthcare organizations accountable.
• 18:41
  And if there's only one, it's sort of like, okay, yeah, we did our best.
• 18:44
  If there's two, uh, in a city, then it actually makes it easier to, to measure it.
• 18:49
  And Massachusetts is a good place.
• 18:50
  I mean, keep in mind, these are all not for profit.
• 18:53
  Organizations and they have a mission.
• 18:55
  They have some accountability and there's an opportunity the same way you had in Massachusetts Romney care kind of leading the way to Obamacare.
• 19:02
  There is a real possibility to do it in Massachusetts.
• 19:05
  John.
• 19:05
  So that's my part.
• 19:06
  I'm going to put my Red Sox hat on if I can find it.
• 19:08
  I think I burned it up though.
• 19:09
  I based on their performance this year.
• 19:13
  I'd be much more focused on the Celtics.
• 19:16
  Um, so David, I think accountability is a pretty good place to wrap on.
• 19:20
  Thank you.
• 19:21
  Yeah, John, I would agree with that and I'll hold you accountable for not running over in our session.
• 19:26
  I'll say that's it for yet another episode of Care Talk.
• 19:28
  We've been talking about Harvard and cancer.
• 19:31
  I'm David Williams, president of Health Business Group.
• 19:35
  And I'm John Driscoll, the president of Walgreens Health.
• 19:37
  If you like what you heard or you didn't, please subscribe on your favorite service.