Solve Big Questions by Joining Forces

Andrew L. Pecora, MD

I have had the privilege of forging several partnerships of physician groups and, more recently, hospitals and hospital systems. Not surprisingly, I have found the core reasons for merging—scale and efficiencies—are no different whether it involves small groups of physicians (my first merger involved NNJCA Capital and Hackensack Medical Center in 1994) or a partnership between big healthcare systems (Memorial Sloan Kettering Cancer Center and Hackensack Meridian Health in 2016). Some scale may be needed to determine the value of any business initiative. An analysis of work flow to improve office efficiencies can be done successfully in a small group of 5 to 7 physicians. However, determining the best pattern of care for the best clinical outcome at the lowest total cost may take over 1000 physicians working together. To get physicians to work together, you need an organizing structure and the drive to create partnerships.

In merging the 10 largest practices in New Jersey to create Regional Cancer Care Associates (RCCA), of which I am a member, our intention was to work together to create value for our patients and society. We have done that partly be addressing one of the most vexing problems facing medicine and society today—the cost of end-of-life care. Nononcologists should tread carefully here. It is so easy to try to solve this problem through simplistic measures such as, “Did you administer chemotherapy within 3 days of death?” Ten years ago, when we did not have immunotherapy or targeted therapies or genomic analysis for potential driver mutations, it might have been plausible to think in terms of being able to predict the date of death of your patient. Today, with the power to extend life with new drugs, it is not possible to reliably predict the date of decease, and we can never forget that without a validated predictive tool to guide physicians we place our physicians in moral jeopardy by making them choose whether to save the life of a patient or conserve precious healthcare resources.

Through the power of operational scale, the RCCA physicians and their colleagues at the data analysis startup COTA have developed a tool for guiding timing of palliative care consultations. COTA created a patient-reported instrument called “Living with Cancer” and completed assessment on overall survival in advanced cancer patients. According to a 2015 study, the tool was able to identify patients for whom end-of-life-care discussions would be appropriate. A larger, 1024-patient survey was completed at 7 cancer care centers in October 2016 and the findings will be reported at the 2017 ASCO Annual Meeting, June 2-6 in Chicago. The results are striking and will be helpful. This is a small but significant example of using partnerships and big data to improve clinical outcomes and reduce total cost of care. There is much more to come.