1. The Importance of a Medical Home for Cancer Patients And How We Might Get There Richard C. Wender, MD Alumni Professor and Chair Department of Family & Community Medicine Thomas Jefferson University Immediate Past President, American Cancer Society

2. The American Cancer Society: 2015 Goals In May 2002, the ACS approved a challenge goal for the nation to achieve a 50% reduction in age-adjusted cancer mortality by 2015 from the 1990 peak

3. Progress Is Being Made A midpoint report revealed approximately a 1% annual decline in cancer mortality from 1990-2002 315,000 cancer deaths were prevented On current pace, 1.9 million cancer deaths will be prevented by 2015

4. But We Have A Long Way To Go We’re on a trend to achieve about half of the 2015 goal Accelerating progress to meet the goal will prevent an additional 2.3 million deaths Byers, T et.al. Cancer 2006; 107

5. For The Most Part, We Understand The Root Causes Of Our Successes

6. Copyright ©2007 American Cancer Society From Jemal, A. et al. CA Cancer J Clin 2007;57:43-66. Age Adjusted Mortality For Men – 1990-2003

7. Copyright ©2007 American Cancer Society From Jemal, A. et al. CA Cancer J Clin 2007;57:43-66. Age Adjusted Mortality For Women - 1990-2003

8. Key Interventions That Are Working or Have Worked 1.Reduction in smoking – particularly in men 2.Improved breast cancer early detection (mammography). And treatment of early disease 3.Colon cancer reduction in incidence due to polyp removal and, possibly, estrogen, NSAIDS, and folate in women

9. Key Interventions That Are Working or Have Worked 4.Prostate cancer detection and treatment 5.Improved therapy for most cancers, particularly childhood and hematologic malignancies

10. But we asked: What will it take to get all the way to our goals to ultimately win the cancer fight?

11. What Will It Take To Achieve 2015 Goals And Beyond? A cancer healthcare agenda driven by public health considerations A public health analysis of research investment An emphasis on primary care Expanded access to primary and cancer care services Institution of systems of care to replace the clinician as the sole pilot of care Payment mechanisms to support these systems

12. We must follow two roads to healthcare reform: Improving coverage Improving health care delivery Any viable solution must control cost

13. Addressing Coverage – A critical step to winning the cancer war

14. Impact of Insurance on Stage at Diagnosis for Breast Cancer

15. Odds of More Advanced Stage at Diagnosis, Colorectal Cancer, NCDB, 1998-2004 InsuranceStage II vs. I Stage III or IV vs. I Private1.0 (Ref.) Uninsured 1.9* 2.0* Medicaid 1.4* 1.6* Medicare Age 65+1.0 Race Non-Hispanic White1.0 (Ref.) Non-Hispanic Black 1.1* 1.3* Hispanic 1.1* *Odds ratio is significant at the 95% confidence level. Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of diagnosis, and facility type.. Source: Halpern et al, 2007 (manuscript in preparation)

16. Consequences of Financial Costs of Cancer by Insurance Status Declared bankruptcy Borrowed money from relatives Contacted by a collection agency Unable to pay for basic necessities like food, heat, or housing Sought the aid of charity or public assistance Borrowed money/got a loan/another mortgage Used up all or most of savings Percent who say each of the following happened to them/their family member as a result of the financial cost of dealing with cancer… Source: USA Today/Kaiser Family Foundation/Harvard School of Public Health Cancer Survey (conducted August 1 – September 14, 2006)

17. Improving Health Care Delivery Infrastructure: Increasing Access To The Primary Care Medical Home

18. An Emphasis on Primary Care Services

19. Why Is Primary Care Important? Starfield 09/04 04-134 Better health outcomes Lower costs Greater equity in health Starfield 09/04 PC 2945

20. Higher Primary Care Supply is Associated With: Increased likelihood of early detection of: Breast Cancer Cervix Cancer Melanoma Colon cancer Starfield 03/06 IC 3384

21. An orientation to primary care reduces sociodemographic and socioeconomic disparities (inequities) in access to health services in population health Starfield 03/06 IC 3383

22. Medical home is similar to global warming. The evidence is clear. It’s just a matter of whether we have the will to do something about it

23. What is the road to health care reform that includes support for the primary care medical home?

24. Focusing On Reform Through The Cancer Lens - A Smart Strategy

25. Health care top domestic issue Health care remains the top domestic issue for Americans in the upcoming presidential election. Source: Kaiser Family Foundation, Kaiser Health Tracking Poll: Election 2008, October 2007.

26. Values and barriers Health care has become a core value. The concept of “quality affordable health care" is more appealing than “universal coverage." Source: Lake Research Partners, November 2006.

27. Voters are insured and worry about health care costs Health care is salient to voters. Americans are worried about the rising costs of health care. Feel they are getting less for more. Sources: Lake Research Partners, November 2006; Kaiser Family Foundation, Health Security Watch, October 2007.

28. Costs of covering uninsured Majority of the uninsured (80%) are working families. Feel “sliding scale” works While voters agree everyone should have access to health care, they don’t want to pay for the “undeserving.” Source: Lake Research Partners, November 2006.

29. Voters feelings about private insurers and government’s role Voters often support reform proposals in principle —but pull away when it may adversely affect them personally. Insurance and drug companies are making excessive profits. Government has a role as a watchdog. Source: Lake Research Partners, November 2006.

30. Preventive care as stepping stone Seen as “common sense” investment. Guaranteeing access to preventive care is a clear role for rules and government. Preventive care is potential escalator. Prevention seen as encouraging personal responsibility. Source: Lake Research Partners, November 2006.

31. Most Important Diseases or Health Conditions the Government Should Address? Harvard School of Public Health and the Robert Wood Johnson Foundation, Americans’ Views of Public Health, April 2006.

32. Cancer Screening for all Americans most popular among proposals Source: Lake Research Partners, November 2006. 74% 68% 66% 65%

33. Voters want doctor-patient relationship safeguarded Source: Lake Research Partners, November 2006. 90% 91%

34. When talking about health care… Words to Use Quality affordable health care American health care Sliding scale Prevention Smart investments; investing in the future Choice Rules Guaranteed Giving people control; peace of mind Standard package; affordable health plans Public/private partnership Government enforcement/watchdog Words to Avoid Universal coverage Medicare for All; A system like Social Security; Canadian Style Health Care Free Wellness Inexpensive Competition Regulations Required Government health care for all Basic health care Public health care Government health Source: Lake Research Partners, November 2006.

35. Cost Considerations May Block National Reform Efforts

36. Constraints The national debt The federal deficit Expiration of Bush tax cuts in 2010 Medicare growth Medicaid growth

37. Nation Debt: $9.0584 Trillion (October, 2007) Growing by $1.42 billion/day $29,866 per person $58,954 per worker Median household income: $48,206 (2006) (average of 2.6 persons per household) Mean household income: $60,528

38. The Federal Budget Deficit About $158 billion for 2007 (FY ended 9/30/07) OMB and CBO predict deficit through 2012 (and unofficially much longer, based on current tax and entitlement policy) Last federal surplus was 1998-2001

39. Bush Tax Cuts All the tax cuts enacted under President Bush expire on Dec. 31, 2010 If allowed to expire, there would be a small surplus for 2012-2017, but then deficits begin again because of entitlement growth Extending all of the Bush tax cuts 2010- 2014 would cost an additional $1.2 trillion, and it grows thereafter.

40. Entitlement Growth

41. Implications The next president and Congress are going to be engaged in an intense debate about the budget and taxes. The budget debate will inevitably raise the issue of changing entitlements. There will be very little “free” money for health care reform, at least until the tax extension issues are resolved.

42. So What Should We Be Doing?

43. Health Care Reform Will Require New Collaborations... And Some Strange Bedfellows

44. The Massachusetts plan was designed by putting the insurance companies, bastions of capitalism, government, and die-hard liberal reformers in the same room…and refusing to give up.

45. Will National Reform Occur Soon? National reform will demand: – A president willing to put his or her reputation on the line – A congressional majority of the same party – Broad public demand – Confidence that it can be done

46. States Will Lead States have variable levels of uninsurance Variable economic resources Variable political environments

47. States Need To Lead We need to draw the roadmap to access – states can be the experimenters When 20 states make meaningful change, national change will look more feasible

48. Enlist The Cancer Community As A Supporter Of Medical Home.... And Medical Home Advocates Should Embrace A Cancer Focus

49. The ACS Vision By 2015, everyone will have timely access to the full range of affordable evidence-based healthcare necessary to optimize health and well-being

50. Keep A Human Face On The Debate