Government Relations

Government Relations

George W. Sledge, MD, FASCO

Jan 20, 2011

ASCO devotes a considerable portion of its efforts and resources to government relations and has an increasingly active Government Relations Committee. The GRC is a relatively new committee, having replaced its previous iteration, the Government Relations Council, just two years ago. I am writing this post on my way home from the GRC meeting.

As you can easily imagine, we as an organization are wrestling with the fallout of last year's passage of the Affordable Care Act (aka health care reform and Obamacare). The House of Representatives voted today to repeal the legislation, a bit of political theater (we were assured by both Republican and Democrat congressional staffers) that will be DOA in the Senate. Even so, both the House and the Senate are likely to make tweaks to the original bill, which was a messy stew of trade-offs and compromise. What these will involve will become apparent in the near future--the Senate staffer we spoke with referred to these as "rifle shots" as opposed to last year's noisy cannonade. Meanwhile, the important working out of the new bill's details are left to the federal agencies, and ASCO is actively engaged in trying to influence this process for the benefit of our patients.

The bigger issue is that of cost. Everything in Washington revolves around what staffers call the "CBO score," the CBO being the Congressional Budget Office, which is tasked with computing the cost of everything. Health care is very, very expensive, and (appropriately, I think) no one quite trusts CBO projections on health care, which have been remarkably hard to predict.

Why is health care so astonishingly expensive, and why do health-care costs violate the economic laws of gravity? What drives the ever-escalating costs of American health care?

The answer is "lots of things." Our dysfunctional multipayer system puts a premium (literally a premium) on a large and no-value-added bureaucracy that infuriates physicians and patients. Our cost-plus approach to drugs, imaging and procedures, with its a la carte menu of pricing, is a perverse incentive preventing the rational use of new technology. The huge onslaught of expensive new technology often overwhelms the system's digestive ability: we eat too many of the pretty new sweets and then get sick when someone hands us the bill.

Atul Gawande, fast becoming our most thoughtful writer on the health care system, points out another cause in the current issue of the New Yorker magazine: the tendency of a few patients to generate huge costs. Pointing to Camden, New Jersey, he writes that 30% of that impoverished city's health care costs are generated by just 1% of all patients. Some of these costs are unavoidable ( there are really, really sick people who require really, really expensive care), but much of the cost is waste. People who don't take their pills (for the usual reasons: cost, poor education, and flat-out bad compliance related to social and psychological dysfunction) keep bouncing back to ERs and ICUs when their often very treatable conditions go untreated. Focusing on controlling the costs associated with the 1% can result in huge cost improvements as well as better health care. These improvements don't require more $50,000 drugs: they rely on social workers, nurses, and physicians talking to patients. Oncology is at the high-end, high-tech part of medicine, with Provenge and PET scans and their relatives driving cost, but I suspect that the "high-utilizer" approach described by Gawande would be operative for oncology as well.

We need to re-think the equations surrounding cost and value in cancer care. There is no question but that both sides of the aisle on Capitol Hill would like us to move from "pay for service" to "pay for performance," though no one is quite sure how this would happen or even how "performance" would be defined. The Affordable Care Act authorizes Medicare to experiment with new payment models in pilot projects and in new creations such as Accountable Care Organizations (ACOs). This is certainly on ASCO's radar, and we hope to actively engage with CMMS on this.

A central part of the cost/value discussion is quality. Here we as an organization have something solid to offer. ASCO has, through its guidelines and its QOPI process, led the way in defining what constitutes high-quality cancer care. Regardless of how the economics of health care ultimately shakes out, we should insist on maintaining high quality of care for all those afflicted with cancer. Because this is a moving target, we need continued updating and constant measurement. Health care professionals involved in the day-to-day care of cancer patients are the right people to generate and evaluate quality measures.


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