Podcast interview with Cancer Treatment Centers of America CEO Steve Bonner (transcript)

This is the transcript of my recent interview with Cancer Treatment Centers of America CEO Steve Bonner.

David Williams: This is David E. Williams from the Health Business Group. I’m speaking today with Steve Bonner, CEO of Cancer Treatment Centers of America.


Steve, thanks for joining me today.


Steve Bonner: You’re very welcome, David. It’s great to speak with you again.


David Williams: What is Cancer Treatment Centers of America and how does it differ from other well-known cancer centers?


Steve Bonner: Cancer Treatment Centers of America is a growing chain of hospitals that specialize in and treat only cancer. We tend to see later-stage, more complex patients, because they get the diagnosis and stay at home until it becomes more complex. At that point they then, go looking.


We have as comprehensive and complete an array of technology and talent for traditional cancer therapy under one roof as you can find anywhere. What really sets us apart is our commitment to a holistic and an integrated style of care. The traditional therapy treats the tumor but cancer is not the tumor, it’s the malfunction of the basic immune system. Therefore we provide a very robust array of complementary therapies, which include nutrition plans, naturopathic intervention, mind and body medicine, spiritual support, exercise, Reiki, yoga, Pilates and pain management, which includes acupuncture as well as more traditional methods of pain management.

We integrate these therapies for every patient in a way that you  don’t see elsewhere. If you go to the finest cancer providers, you’ll be able to see a great medical oncologist and a cancer-trained nutritionist and naturopath. However, those professionals will never talk to each other. We structure a team of those professionals around each patient and that team stays with that patient throughout  the course of their treatment at  CTCA.


David Williams: I’m curious about how you think about the definition of quality in patient care because  a more holistic and integrated approach, is more difficult to measure.

Steve Bonner: Exactly. Our corporate DNA is grounded in the philosophy of patient-centric care. Of course, everybody says that, but we were created by an international merchant banker and a libertarian whose mother got cancer. Our founder set out to create something that structurally keeps us focused on the patient. As a result, when it comes to quality, the question we keep asking is, for each patient, what is the patient’s definition of quality and how are we doing in achieving that?


We have our own extensive measures of the quality of the experience. We measure and publish data from the patient point of view, using a Bain Net Promoter Score and also do the conventional Press Ganey Measurement. – We also include HCAHPS, Leapfrog and many others.


We believe that as an industry, we have a long way to go to really understand quality from the patient’s point of view. When we talk about HCAHPS and Leapfrog, they’re useful, but they’re more for the industry’s point of view than the patient’s point of view.


We have two major initiatives that are underway to try to help us better understand quality measures and then provide information about quality that we think can lead to some breakthroughs. One is a new piece of research that we’ve just released called the “The Cancer Experience”. It is a national study of patients and caregivers. The Cancer Experience is composed of a thousand cancer patients, a thousand caregivers, and family members of cancer patients all of whom are people who have been treated in centers across the country. This isn’t specific to CTCA patients although our patients are included.


The headline of this study that was surprising to us is that one in four of these patients and caregivers are dissatisfied with the care that they’ve received across the US. We note that 20 percent of these patients have left the place they went first for care and have gone somewhere else as they try to find the quality of care and the price of care that matches their expectations.


The survey goes on to point out that there are three major events or elements of care that really drive the dissatisfaction. The first is that patients know how complex the disease is, know how complex the treatment is going to be, and know how  challenging it’s going to be to understand it.  They expect and want us to provide them with a care quarterback the minute they come into the hospital that can stay with them throughout their care. A person that understands their disease understands what we can do and can help them navigate the system.


The second issue is that patients want an integrated care team to make sure that they get care for this disease that addresses the mind, body, and spirit, not just the tumor. The survey told us that 86 percent of the patients and caregivers wanted an integrated team, but fewer than 70 percent actually were able to have one.


The third major driver of this dissatisfaction is pain management.   It is easy to imagine how important that is to a patient and to a caregiver.  It was interesting that the caregiver actually felt more strongly about pain management than the patients did. Half the population in the survey said they did not get the pain management that they needed and wanted to allow them to be able to navigate their treatment and get to the best possible outcome.


The other major activity that we’re involved with is to try to help the industry and help us understand quality from a patient’s point of view.  In response to this we’ve created a partnership with the National Patient Advocate Foundation, which is not-for-profit. We’re underwriting a piece of research that will be presented a year from now, next April. It is another survey of cancer patients and family members that will allow them to define the cancer value index in their terms.


It’s basically  trying to create the JD Power of oncology, where the association of research will conduct this research, they’ll publish the research and then, they’ll continue to manage it in a way that will allow providers to give them our performance information. They can then publish it in a way that will make it much more comparable for patients and allow them to more intelligently navigate the industry as they seek a combination of quality, price and as a result, value.


David Williams: I’d like to ask you more about the role of competition in terms of improving quality. You mentioned that your founder comes from a libertarian background and merchant banking. And of course you’re a for profit organization. In lots of places in the economy, competition drives quality, performance and value but not necessarily in health care. What role does competition play in driving quality in health care, both in oncology and more broadly?


Steve Bonner: Competition is one of the most powerful drivers of quality, cost and value that is available to us. An empowered consumer with choice will walk, talk and teach us what real value is. If we then compete based on those terms, we’re going to see quality naturally go up and price naturally come down.  Even in health care today — LASIK or elective plastic surgery — where it’s up to the patient to decide and pay you see continued improvement in the quality and in the technology. And you can see the price continuing to come down.

The way we’ve constrained competition in health care is a major factor in how expensive care has become and how elusive true quality is. That’s part of the reason we’re sponsoring these two significant efforts to engage the consumer to teach us how they want to define quality.


David Williams: In most markets, including ones you’ve described, there’s usually a market price for something, and the supplier sets their prices and customers either pay it or they don’t. Health care is also a little different where you have commercially-insured patients and you have Medicare and Medicaid patients. Medicare,  in particular, will tend to pay a lot less than what the commercial patients are paying.


In an area like oncology, what impact does that have on providers and on patients? What are the policy implications of this often wide disparity between the commercial reimbursement rates and what government programs are paying?


Steve Bonner: The implications are profound. I may back up a step and say that if we want competition to control the market, then we have to enable that competition with much better information, including information about price.


David Williams: Let me ask you about the recent Reuters Special Report that I’m sure you’ve seen. It was taking a look at your company’s claims that survival rates are higher for your patients than for other patients. It concluded that those claims couldn’t really be substantiated because there were differences in your patient population versus those you were comparing it with. Can you just provide some commentary on how you look at this issue more broadly and address some specific questions that came up in that Reuters Report?


Steve Bonner: We heard that these reporters were working on a story and we reached out to them and invited them to include us in the dialogue, which ultimately they did at some level. We invited them to come and visit our hospitals and talk to our patients and  understand the patient experience, which was part of what they were writing about. We explained to them what we’ve done with the publication of our outcomes and the rationale behind it and the evolution of it going forward.


We did tell them that all the data that we published on our website on outcomes is vetted by an independent research team at Washington University and offered them the opportunity to talk to the research team. They declined to come and  look at it. In my opinion, they wound up drawing unsustainable conclusions and making observations that simply aren’t supportable as they presented them.


We’re either the first or the second or the third in oncology to put any outcomes data on our website — but we publish all the outcomes on analytic patients who come to CTCA. These are patients who had not been treated elsewhere. We publish that by length of life, quality of life, match to location and stage of disease. It’s very clear that’s what is published.


The other way to come at it is what we don’t publish. We don’t publish data on the patients who have been treated elsewhere before they come. The question is why, and the reason is because we haven’t so far figured out a good frame of reference to offer people. With analytics of the disease, we have the SEER and NCI database and that’s what we use as a point of reference.  We think it’s fairly comparable to this segment of our patient population.


Where we have a fourth-stage pancreatic cancer patient who also has diabetes and a heart condition and has been treated in some very unique way in two or three organizations, to just publish their length of life data, we don’t think would be helpful to patients. We haven’t published that. We’re in the process of relooking at that and maybe we just need to put that out there and then, we’ll take on the questions as they come.


Some of the organizations that the reporter quoted in criticizing our methodology are organizations that so far had not published one statistic with respect to their own outcomes. They don’t publish HCAHPS data. They don’t publish Press Ganey data. We ask ourselves how valid and relevant and reliable are these as critics?


We do have a unique population and that’s a fair observation. We talked about the major elements of it. They are very engaged patients. Most are patients who have been diagnosed and treated elsewhere, they’re not happy, and they’re willing to travel. Our average patient travels 250 to 300 miles to come to us for care. These are people that really are in the game and are going to do what they need to do to find a cure.


They tend to be a more advanced stage population than  others. The article suggested that we culled out from inquiring patients those who were more advanced with their disease and that’s absolutely unsupportable.  We see many patients who had been told by MD Anderson, Sloan-Kettering, Cleveland Clinic that there’s nothing more than can be done for them at those institutions and to go home and get their affairs in order. We take those people in. We can introduce them  to patients who have heard that same thing from those institutions and others three years ago, five years ago, ten years ago.


We’re here for that kind of patient and do everything we can to bring them in. Every patient has to navigate their insurance structure, and that’s what culls out patients, not CTCA.  When the patients want to come to us, we’ll work very hard with their insurance company and with their employer to try to make sure everybody understands the situation. We look at what other options might be available for the patient and try to open doors that might otherwise be closed.


We see some insurance companies and some employers being much more flexible with these patients who clearly have no options elsewhere.  If a patient’s in an HMO and they’re not willing to let them opt out of the HMO into some sort of a PPO coverage, there’s really not going to be a way for them to come to CTCA. That’s the insurance market operating, not us culling patients.


David Williams: As you look at the next three or five years,  do you see any expansion opportunities? Is it putting facilities in different geographies from where you’ve been? Is it offering new kind of services? Where do you see the company heading over the medium term?


Steve Bonner: The future of health care is a really an exciting future to behold, and especially in oncology. For CTCA, we are looking at trying to make ourselves more conveniently accessible to patients. In the last seven years, we’ve gone from one center to five centers and we’re looking at a sixth center. We’re looking at the possibility of some less intensive centers that  we can put many more of them around the country and offer cancer information, central diagnostics and routine treatment. The therapeutic future may be even more exciting than that to us.  We think that the next major breakthrough in oncology is clear and that’s going to be understanding the disease at a genomic level and then being able to match known therapies much more precisely with the genomic abnormalities that a person’s expressing.

We’re working very hard on genomic innovation. Today, when you get cancer, a tumor shows up in one part of your body, insurance company providers go to an FDA-approved drop-down menu that says “if you have that cancer in that body location, this is the treatment that’s performed best in large population, placebo-controlled double-blinded studies”, and so you should get that. Every insurance company will pay for it and if you stay in network they’ll get it for you at a 40 percent discount.


The reality is that those large population studies produce the best tumor response in maybe 40 percent of the population. We’re prepared to pay for 100 percent of the population to get the therapy even though we know statistically only 40 percent are going to respond well.  As we dig underneath that, we find that your pancreatic cancer and my liver cancer may actually be driven by the same genomic abnormality, but our systems express tumors different., You’re going to get one therapy and I’m going to get another therapy. If we understood it genomically, we’d both get the same therapy and avoid a lot of unnecessary therapy that we deliver through the system today.  This is one way to take significant cost out of oncology care and really accelerate and enhance the quality and effectiveness of care. That’s the most exciting thing we see in the future.


David Williams: I’ve been speaking today with Steve Bonner. He is CEO of Cancer Treatment Centers of America. Steve, thanks so much for your time.


Steve Bonner: Thank you, David. Take care.

May 10, 2013

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