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Transforming America’s Healthcare

Transforming America’s Healthcare. Edward E. Partridge, MD, Director UAB Comprehensive Cancer Center Professor of Gynecologic Oncology Evalina B. Spencer Chair in Oncology. Alternate Title. The Budget Deficit US Healthcare This Disparities Thing. The American Cancer Society.

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Transforming America’s Healthcare

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  1. Transforming America’s Healthcare Edward E. Partridge, MD, Director UAB Comprehensive Cancer Center Professor of Gynecologic Oncology Evalina B. Spencer Chair in Oncology

  2. Alternate Title The Budget Deficit US Healthcare This Disparities Thing

  3. The American Cancer Society We are dedicated to helping People: • Get Well • Stay Well • Find Cures • Fight Back

  4. How Can We Provide Adequate High Quality Care (to Include Preventive Care) to a Population That Has So Often Not Received It?

  5. All Sites - Mortality Rates By Year of Death - All Races, Males and Females 2015 Goal – 50% Reduction from Baseline 1991 Baseline215.1 ( 17.2% from baseline) 2007 178.2 2015 Projected Rate –150.6 (Current trend to 2015 -  30.0% from baseline) (The latest joinpoint trend (2001-2007) shows a -1.6 APC in age-adjusted rates) 2015 Goal107.6 Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard population SEER Cancer Statistics Review 1975-2007.

  6. Deaths averted from 1991-2020 The blue solid line represents the actual number of cancer deaths recorded and the blue dashed line represents projected cancer deaths based on decreasing trends in cancer death rates during 2003-2007. The green dashed line represents the projected number of cancer deaths if rates continue to decline at twice the current rate (2003-2007) beginning in 2013. The red line represents the expected number of cancer deaths if cancer death rates had remained the same since 1990 (males) and 1991(females).

  7. Beyond Healthcare Reform • What was that Debt Limit Debate really about. • Federal Medicare/Medicaid costs are spiraling out of control • In 2010, 23% of the $3.456 Trillion Federal budget ($793 Billion)

  8. Beyond Healthcare Reform • Medicare, Medicaid, and Social Security account for all of the projected increase in Federal spending over the next 40 years. • For the past 30 years, costs per person throughout the health care system have been growing approximately two percentage points faster per year than per-capita GDP. • Most projections assume this pattern will continue through 2050. Over time, the fiscal consequences of this rate of growth in health costs aremassive.

  9. Factor Increasing Cancer Risk in U.S. • The Aging of the population • 30 million over age 65 in 2000 • 71 million over age 65 in 2030 • Western diet/high in calories • Lack of exercise • Smoking/Tobacco use

  10. True Healthcare ReformRequires: • Broad critical thinking • The use of “Evidence Based Care and Prevention” That is: • the rational use of medicine • not the rationing of medicine • We do what we know works and often do not do • We stop doing what we know does not work

  11. Toward an Efficient Healthcare System • Some consume too much • (Unnecessary care given) • Some consume too little • (Necessary care not given) • We could decrease the waste and improve overall health!!!!

  12. U.S. Health Care Spending In 2009, the U.S. spent $2.53 TRILLION on Health Care

  13. U.S. Health Care Spending in Context How Big is a Trillion? 1 million seconds Last week 1 billion seconds Richard Nixon’s Resignation 1 trillion seconds 30,000 BCE

  14. Spending in Context 2009 $2.53 trillion $1.4 trillion $1.1 trillion Gross Domestic Product * Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion) Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis

  15. American Healthcare • 16.2% of GDP in 2006 • 17.3% of GDP in 2009 • 19.3% of GDP by 2019 (projected) • 25% of GDP by 2025 (projected)

  16. Spending: US vs. Other Countries Per capita health care spending, 2006$ at PPP* Per capita GDP ($) * Purchasing power parity. ** Estimated Spending According to Wealth. Source: Organization for Economic Co-operation and Development (OECD)

  17. US Healthcare Outcomes • Are generally worse than in other western countries • True for cancer and other chronic diseases • Canada is a wonderful place!!!!

  18. Healthcare in Three Countries (2010) • Canada Switzerland U.S. • Infant Mortality 5.04 4.53 6.22 per 1000 live births • White Male Life Exp 78.0 79.7 76.8 Years • Per Capita Costs 3173 4011 6096 US Dollars • Proportion of GDP 9.6% 11.2% 17.3%

  19. Overall Quality: Life Expectancy at 65 The US is ranked 12th for Males and 16th for Females Source: OECD, 2006 data

  20. U.S. vs. Canada • CT Scanners per million population. U.S. dominates by 3 to 1 ratio • MRI Scanner per million population. U.S. dominates by 5 to 1 ratio

  21. True Healthcare Reform(An Efficient, Value Driven Health System) • Rational use of healthcare is necessary for the future of the U.S. economy (an issue of U.S. security) • It is possible to decrease costs and improve healthcare by using science to guide our policies • We need to be smart about health

  22. Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB

  23. Equal Treatment Yields Equal OutcomeThere is not Equal Treatment Studies suggest that disparities in treatment may be due to: • Cultural differences in acceptance of therapy. • Disparities in comorbid diseases (including obesity) making aggressive therapy inappropriate. • Lack of convenient access to therapy. • Racism and SES discrimination.

  24. How Can We Provide Adequate High Quality Care (to Include Preventive Care) to a Population That Has So Often Not Received It?

  25. The Future of Healthcare Are American’s willing to be scientific, accept scientific reality and Give up “faith based medicine” and Adopt and appreciate “evidence based medicine?”

  26. Medical Gluttony • Screening tests of no proven value • Treatments of no proven value • Laboratory and radiologic imaging done for convenience. • -Cannot find original. • -Legal defense (real or imagined). • -Tradition.

  27. Treatment versus Prevention

  28. Our healthcare system is heavilly focused on addressing illness. • The system needs to transform to one that places more value on prevention and early detection of disease!

  29. Clinical Lessons Learned Late • Postmenopausal Hormone replacement therapy- • Lidocaine after MI • Hyper-vitaminosis (Vit E, Beta Carotene, Selenium) • Rofecoxib and Celecoxib for arthritic pain • (Vioxx and Celebrex) • Rosiglitazone (Avandia) for diabetes • Erythropoetin

  30. Clinical Lessons Learned Late • Hysterectomy • Caesarian section • Carotid endarterectomy • Coronary Artery Bypass Grafting • Tonsillectomy • Tympanostomy

  31. Clinical Lessons Learned Late • Chest X-ray screening for lung cancer • Urine screening for neuroblastoma • Cryotherapy for prostate cancer • Halsted mastectomy • Adjuvant bone marrow transplant for breast cancer

  32. Screening • Breast - Mammography and Clinical Examination • Colon – Stool Blood Testing, Sigmoidoscopy, Colonoscopy • Cervix – Pap smear (conventional or wet)

  33. Screening • Lung – Spiral CT, 20% decrease, significant side effects of screening` • 99.5% saw no benefit • 0.5% were helped (death prevented) • 3.5% were harmed (unnecessary surgery) • 0.6% were harmed (complication of surgery)

  34. Screening • Lung – Spiral CT, 20% decrease, significant side effects of screening` • 1 in 217were helped (death prevented) • 1 in 4 were harmed (false positive CT) • 1 in 30 were harmed (unnecessary surgery) • 1 in 161 were harmed (complication of surgery)

  35. Fact • Smoking cessation is more powerful at preventing lung cancer death than spiral CT screening. • It is also cheaper!!!

  36. Screening • Prostate – PSA, effectiveness is a question mark and still the focus of study

  37. ACS Leadership Roles

  38. Prevention and Early DetectionLeadership Roles • Breast cancer • Colorectal cancer • Reduce tobacco use • Nutrition and physical activity

  39. Breast Cancer There has been a 30% decline in breast cancer death rate since 1991 (57,000 deaths averted) • Treatment has improved dramatically • Screening Rates: 53% by NHIS 62.1% by BRFSS • A substantial number of women get less than high quality healthcare.

  40. Prevention and Early DetectionLeadership Roles • Breast cancer • Colorectal cancer • Reduce tobacco use • Nutrition and physical activity

  41. Colorectal Cancer There has been a 30.4% reduction in colorectal cancer mortality since 1991 (77,000 deaths averted) • Treatment has improved dramatically • About half of Americans over 50 get any screening. • A substantial proportion of Americans get less than high quality screening and treatment.

  42. Breast CancerThe Reality • From 1993 to 1997, 561 Black women died of breast cancer in Atlanta. • If Atlanta’s Black population had the Department of Defense Health System Black rate, 330 would have died (231 less) • Lund et al, Cancer 2004

  43. Prevention and Early DetectionLeadership Roles • Breast cancer • Colorectal cancer • Reduce tobacco use • Nutrition and physical activity

  44. Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2008 Men Women *Redesign of survey in 1997 may affect trends. Estimates are age adjusted to the 2000 US standard population using five age groups: 18-24, 25-34 years, 35-44 years, 45-64 years, and 65 years and over. Source: National Health Interview Survey, 1965-2008, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

  45. Lung Cancer • 14.1% reduction in mortality to 2009 • 2009 adult smoking prevalence of 20.6% (CDC National Health Interview Survey) • 2009 teen smoking prevalence of 19.5% (CDC Youth Risk Behavior Surveillance System)

  46. Prevention and Early DetectionLeadership Roles • Breast cancer • Colorectal cancer • Reduce tobacco use • Nutrition and physical activity

  47. Poor Nutrition and Lack of Physical Activity • Obesity, high caloric intake, and lack of physical activity is increasing rates of: • Diabetes • Cardiovascular Disease • Orthopedic Injury • Cancer

  48. Nutrition and Physical Activity • Obesity, high caloric intake, and lack of physical activity has the potential of being a greater cause of cancer in the U.S. than tobacco by 2030 • We are currently not able to model this in an acceptable fashion but it is causing a rise in cancer incidence

  49. Summary of Cancer Mortality by Body Mass Index Women 1.4 1.5 1.5 Colon & Rectum (> 40) Multiple myeloma (> 35) 1.7 Ovarian (> 35) 1.9* 2.0 Liver (> 35) 2.1 All other cancers (> 40) NHL (> 35) 2.1 Breast (> 40) 2.5* 2.6* Gall bladder (> 30) 2.8 All Cancers (> 40) 3.2 Esophageal (> 30) 4.8 Pancreas (> 40) 6.3 Cervical (> 35) Kidney (> 40) Uterus (> 40) Relative Risk and 95% CI (based on never smoking women) Calle et al. NEJM 2001

  50. Summary of Cancer Mortality by Body Mass Index Men 1.3 1.5 1.5 Prostate (> 35) NHL (> 35) 1.7* All cancers (> 40) All Aother cancers (> 30) 1.7 Kidney (> 35) 1.8 1.7 1.8 Multiple myeloma (> 35) Gall bladder (> 30) 1.9* Colon & Rectum (> 35) 1.9 Esophageal (> 30) 2.6* Stomach (> 35) 4.5 Pancreas (> 35) Liver (> 35) Relative Risk and 95% CI (based on never smoking men) Calle et al. NEJM 2001

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