Sophisticated Solutions for Complex Cancer Care

In a recent podcast episode, Natalya Gertsik, vice president of Clear Cancer Solution Management at PHM, and a contributor to the 2023 Springbuk Employee Health Trends report, sat down with our team to discuss the three main deficiencies in our healthcare system that can make cancer care an up stream battle.

Listen to the full podcast episode here.
Download Employee Health Trends 2023 here.

Mike
Hello, and thanks for joining us for Healthcare On the Rocks: Employee Benefits with a Twist. I'm Mike Pattengale, mid-market practice leader.

Jennifer
And I'm Jennifer Jones, enterprise practice leader at Springbuk. According to a 2023 survey conducted by the Business Group on Health, cancer has overtaken musculoskeletal conditions as the top driver of large companies' healthcare costs.

In Springbuk's annual Employee Health Trends report, our data scientists and clinicians looked deeper into the data to uncover what was driving the surge in spend, including whether rising costs were due to the increase in cancer rates or costs of treatment.

Mike
Springbuk also consulted with cancer care experts at Private Health Management, or PHM, to provide additional insights. Today we're talking with Natalya Gertsik, vice president of Clear Cancer Solution Management at PHM, and a contributor to the 2023 Employee Health Trends report. Natalya, welcome to the show.

Natalya
Thank you. Glad to be here.

Mike
Why don't we start with you telling us a bit more about your background and what PHM does.

Natalya
Yeah, so, I have a PhD in biochemistry from Weill Cornell with a focus in Alzheimer's disease drug development. And after that I spent a little bit of time in management consulting at McKinsey, and now I lead PHM's Clear Cancer Solution. And the focus of that really is to provide the best of what's possible in cancer care to patients, to families, and also to organizations. And the premise is we don't think it's acceptable that most patients aren't benefiting from the latest advancements in science and they're not benefiting from precision medicine as much as they could be. And you know, in our observation, precision medicine is inconsistently applied at best.

Natalya
Our goal really is to move patients to the right side of the outcomes bell curve, to shift that normal distribution to see more patients benefiting from that tail end on the right side, where you've got much better outcomes than you would on average – we take the hardest cancer cases. For employers, those are also typically the most expensive ones.

And in terms of what we provide to employers is it's really a combination of advisory services and care management services.

And so what that does is on the advisory side of things is really uncovering the problem. Let's diagnose the cancer problem in your population.

And once we're able to do that in a data denominated way, let's look at the opportunities to make an impact. And that's where our care management practice comes in and actually on a case by case basis, starts to make an impact on your highest risk cases or the cases that are the highest spend, et cetera.

And ultimately we understand that cancer is a complex disease. And if we're going to tackle it, we need to match it with a service model that is equally robust and sophisticated. And that's why we designed our Clear Cancer offering as this combination of advisory, diagnosing the problem in the organization and care management, solving the problem for those specific cancer cases, which all sort of lays on top of a foundation of clinical sophistication and applied health intelligence.

Mike
Thank you. Well, let's take a step back for our listeners. Could you explain why cancer is such a big problem?

Natalya
Yeah. It really comes down to two components. There's the measurable, it's how much cancer is out there, can we measure it? And then there's the human side. So on the measurable side, we know, including from Springbuk's Employee Health Trends report, the 2023 that just came out recently, we know that cancer is growing in prevalence.

We know that cancer is growing in cost. So the measurable is there and we've measured it. The human side, the sort of intangible side is really important as well, right? It's actually a really devastating disease. It's really scary to be diagnosed with cancer. It affects a lot of people. We all know someone who's been diagnosed.

It involves the whole family. There's enormous emotional and mental health components. It's incredibly complex and we'll talk about that a little bit later. And our healthcare system is actually not designed to deliver patients the best possible outcomes, and that is highly amplified in complex chronic diseases like cancer.

And we've heard from our clients that they actually don't really know how to address it. So employers genuinely wanna help, but they don't know how. And they've said things like, our health plan is there to help our people. We just wanna make sure that they're getting the most out of it. But they admit that they actually have very little control over their cancer spend and actually even less control over the quality of care and outcomes.

And in part because they have very limited visibility into their cancer data.

Jennifer
Yeah, I think that's definitely one problem we commonly hear too is especially with new clients that we have or customers that are coming on is I don't understand. I don't know how to make sense of it. I don't know how to direct people to the right type of care or really how to support their employees, which is traditionally usually their number one priority. So Natalya, can you talk to us a little bit about the deficiencies in our healthcare system as that relates to cancer care, which we know so many people are challenged with?

Natalya
Yeah, and it really falls into three buckets. It's limited access, it's inadequate communication, and the third is inefficiency.

Jennifer
Let's talk a little bit more about the limited access problem.

Natalya
Yeah. So most employers know that access is a problem like that. That's certainly not a new concept to anyone. We think about that typically as a geographic access problem. So if you don't live near certain providers, you won't have access to those providers, then you're not gonna get treated for certain conditions. And that sort of intuitively makes a lot of sense. But actually, even if you do live near a center of excellence, your access could still be limited. And so yes, we know that the data shows that centers of excellence do on average have better outcomes than community oncologists, but better outcomes aren't optimized outcomes.

And so for patients using a center of excellence, it is a geographically constrained entity. And so you would have to travel if you don't live near one, but the benefits include there are subspecialists with very narrow and specific expertise. They have clinical trials. There's a teaching culture, and they do have superior outcomes relative to some benchmarks.

Natalya
But there are limitations. There's the geographic constraints. Then there's the fact that care actually depends on your doctor, not your institution. And so how do you know you're landing with the right doctor? They're challenging to navigate. They do command premium pricing. And just to reiterate, like even inside a COE, your access is still limited.

So for example, they'll refer you to their own clinical trials if it's appropriate, which may not necessarily be the best clinical trial for you. There may be another clinical trial across town. You are not actually gonna get access to that one. And so we think that everyone should be able to benefit from the expert guidance in a geographically unconstrained way.

And so that's where our independence clinical excellence model comes in.

Mike
And digging deeper on that model. Can you share how your independent clinical excellence model overcomes those geographic constraints to provide expanded access?

Natalya
Yeah, absolutely. So we solve for the access problem in two ways. One is getting the right expert regardless of geography, and two is access to cutting edge treatments. So on the expert side, it's fundamental. You connect the patient to the right experts regardless of where the patient lives. Typically it doesn't happen that way, right?

So this is different than the way the healthcare system works. And it, it involves coordination that involves some logistical coordination, right? Anytime multiple institutions are involved, you may be getting treatment close to home, but you may have a advising or consulting expert weighing in on your case.

So there are some logistical additional complications that come with that. We take care of the logistics of all of that. We take that off your plate the shipping of specimens, sharing of medical records, et cetera. We take care of that. We think that the extra hassle your life is worth it.

Natalya
At the end of the day, we know that identifying the right provider is better for outcomes and also for costs. We don't have to send everyone to a brick and mortar COE that commands premium pricing. Your best doctor may actually not be at a COE. And then the second part is this access to cutting edge treatments. We have a dedicated biomedical research arm of PhD scientists that stay on the cutting edge of treatments across cancer diseases. We are a resource to patients to understand what's available and what the sort of efficacy and safety of those options are.

But we're also a resource to physicians. We really help doctors operate at the top of their game because they have this research team that's helping them stay up to date on the latest and greatest for their patients.

Mike
Previously you had mentioned inadequate communication as a deficiency in our healthcare system. How do you see that impacting the quality of cancer care?

Natalya
Yeah. And so I would group that into three sort of communication buckets. So there's communication that happens between doctors. There's communication that happens between doctors and patient. And then there's the communication of the history of the disease to the provider. Like has the history of the case been communicated to the provider in the way that they fully understand the case? And so when it comes to communication between doctors and patients, I think we all know that patients are not receiving the information they need to make informed decisions about their own health. And there is a power and balance between patients and the healthcare system. And so an example that's thrown a lot a around a lot is you would never buy a car without understanding the details around cost and quality, but you do that with your health pretty much all the time. And it's because the risks and benefits haven't been properly communicated to you. And doctors do have different opinions about the same case, and that's because there are multiple ways to solve a health problem. So what you as a patient need to figure out is what's the right one for you?

And we help you do that. So we mine the data and we convert it to actionable insights so that you can determine the right action for you. And then there's the other communication component of is the physician receiving all the information that they need on the case If they are receiving it, that means they need to receive the medical records that are pertinent to the case and they need to have the time to review those records, and physicians don't get paid to review medical records. So how often is that really happening? We make sure that the physicians have all of the information they need to make informed decisions on the case. We summarize the most important information in the way that is digestible in a couple of pages that they can look at and make quick decisions about what's working on what isn't.

I mean, we even include biomarker tracking. You could see over the course of time how a patient's biomarkers responded to a certain disease and that that kind of information would take you hours if you were just trying to glean it from medical records.

Mike
Great. Can you share with us just an example of maybe a case or case study to really bring this to life for our listeners?

Natalya
Yeah, absolutely. And there are many. I'll give you an example of one where we had um, 45 year old male with stage three B colorectal cancer. He presented with a low rectal invasive adenocarcinoma, and before he came to PHM, multiple surgeons had recommended a surgical procedure with a permanent ostomy, which basically means that the waste would be collected outside of his body. And for cancers that are too close to the rectum, where the surgeon can't reattach the bowel after the procedure, this is typically the type of procedure that is recommended. Now, the other type of procedure actually avoids a permanent ostomy, and it's when the surgeon puts the bowel back together either during the surgery or sometime after the surgery. And so in this case, the surgeons told him that his tumor was too low for a successful reattachment of the bowel.

And his wish when he came to PHM was for us to save his life, but also to avoid an ostomy. He was young, he had young kids, he wanted to be active. And we were able to identify a surgeon who could remove the tumor and get clean margins, and at the same time, reattach the bowel with what's called a hand stitched anastomosis, which avoided a permanent ostomy for this client. The surgery was performed two years ago. He had the ostomy reversed three months later, so he had a temporary ostomy. We've been monitoring him for recurrence with minimal residual disease testing ever since, and he's been disease free. And remember, this was a stage three B cancer.

Natalya
But those decisions are very hard to make. And you want the right experts on your side when you're making those very difficult decisions. And then the other component actually of the same case is we discovered in our diagnosis of this case, which is what happens in the very beginning, we take in all of the information, we make sure we fully understand the situation and we order any additional diagnostic testing that we need to have that full picture.

We actually discovered he had a factor five liden, which increases likelihood of blood clots. And when he called us at some time during our engagement about a lump above his collarbone, we went on high alert. He had a chemotherapy port and we knew that those can get blocked by blood clots. And so we sent him immediately to the ER, right, like we talk about keeping people out of the ER, and that's critically important. You don't wanna send someone to the ER who doesn't need to be there, but you also wanna be able to do the reverse. You wanna be able to send someone to the ER when you know they need to be there. This was that situation. We called the ER, we let them know about the factor five lidon, and they were able to work him up in no time at all because they knew what the most likely diagnosis of this was right. And so they saved a ton of time, a ton of time was not wasted on unnecessary workups. They identified the issue, which was his port was clogged with blood clots and they were able to put him on anticoagulation therapy all incredibly quickly because they had this information.

And so I think all of these examples of this, just one patient really go to show you how important it is to have a partner on your side who understands your case deeply and sees the whole picture. And if you juxtapose that with the fragmentation in our medical system, how often does that happen?

How often does someone know all of the sort of clinical aspects of your care such that they can act quickly when something comes up?

Jennifer
And those are really some great examples. And I think probably again from the employers or individuals that are listening to this podcast I'm sure they're asking, as an employer, how can I utilize a program like this with my own population? So walk us through what that looks like.

Natalya
Yeah, absolutely. And there's a general sentiment among employers that there's not much they can do about cancer. And so they may be surprised to find that in fact there are things that they can do to gain control of cancer in their population. And it all starts with understanding your company's cancer burden through your claims data.

Natalya
You need to understand your data. That's really step number one. You need to understand the utilization, the cost, the type of cancers, the demographics that are being affected, all of that. And once you have that, and that's where Springbuk can help of on the data side. Once you have that you ask the question, okay, well, where do I focus? And once you have the data, the answer sort of stares you right in the face. You can look at cancer types, you can focus on certain demographics, you can focus on certain high risk groups.

It just depends on what your data's telling you. And so once you have that information, you can get ahead of the cancer. Take a look at the cases that can become your high cost cases. You can adapt your plan design. You can identify cancers early when they're easier to treat. So there's a lot you can do once you have that data.

Jennifer
And are there a lot of commonalities as far as that you see as far as the biggest challenges as far as with employers or even with benefit teams as far as when they're looking to support their members and put a program like this in place? Are there common challenges that exist within that?

Natalya
Yeah, and you know what we hear is that cancer is complex. It's many diseases. It's not one disease. So you know, you've got organ of origin, breast, lung, leukemia. Right. Everybody knows that. But then there are many more sub-cancer types and so the number of genetic permutations is pretty much unlimited.

So it's, it really does present this enormous complexity. And cancer treatments are exploding. So there's a ton of funding and focus and innovation in the cancer treatment space, which is great. There's been enormous progress, but it's actually really hard to keep up and make a difference from an outcomes perspective.

And so there's really no one size fits all solution, and I think that's been a challenge for employers who are used to thinking of point solutions as a solution that can address sort of all of the problems in that condition or that indication.

Jennifer
Yeah, that's I think a really good point to make. And we talked about cancer becoming the most costly condition now for large employers over MSK and we talked, especially in our Employee Health Trends report we talked a lot about the increasing cost of specialty drugs related to cancer, but as we think about cancer as a whole, can you provide us some general statistics around general prevalence of cancer and how expensive it tends to be just on average as far as for treatment of active cancer?

Natalya
Yeah, absolutely. So in terms of prevalence, the EHT report had a lot of really good information. So on average, 1 to 2% of an employer population will have an active cancer in any given year, meaning they'll be getting treatment for cancer in that calendar year.

And to your point, the Business Group on Health surveys showed that for the first time in history, cancer overtook musculoskeletal disease as the top cost driver for employers. And so this is kind of interesting, right? Like cancer was always a high cost condition, but for the first time it overtook musculoskeletal and took that sort of first place, which I don't think anybody is proud of.

But that is nevertheless the situation. And so the question is why, and I have a couple of hypotheses. One is that we employers have actually bolstered their musculoskeletal benefits in recent years. And so they may be seeing the benefits of those programs. And admittedly like we have not done much in the cancer space in that same way.

Natalya
And the second is that actually Springbuk's real-world data that was published in that EHT report shows that the employer sentiment is warranted. You guys actually show that not only is cancer growing in prevalence, but it's growing in cost. Looking over the 2020 to 2022, 3 year period. Right? So that's really interesting because the sentiment that we saw in the BGH survey matches the reality as published in, in Springbuk's EHT report. So employers concerns are clearly warranted.

And then I can talk a little bit about the cost of cancer as well. Again, the Springbuk's EHT report has a lot of really good content on that. So on average 10 to 15% of total health plan spend for employers is attributed to cancer. That's a very significant chunk of total health plan spend. And the Springbuk EHT report showed that costs are rising 4% per claimant in those three years. And what we found in the recent analysis of client data was that the lion's share of cancer costs are actually driven by a small proportion of cancer cases.

So just to give you a sense of those numbers, so this was a 35,000 life group, 4% of cancer members accounted for 55% of cancer spend, and 20% of cancer members drove 97% of cancer spend. So virtually all of cancer spend in this population was driven by 115 people, which means that 15% of their total health plan spend was driven by just over a hundred people.

And that's like a very interesting observation because it starts to really show you the challenges and the opportunities here. Like it's a challenge for obvious reasons, but it's an opportunity cuz you can make an incredible impact on your spend by targeting your highest cost cases.

Mike
So just thinking through this as we start to wrap things up here when it comes to cancer, what can employers do to really improve the outcomes and reduce the spend within their population?

Natalya
Yeah, so I'm gonna talk about six things. It's a lot of things. It's not a comprehensive list, but there are a couple of things you can do. So one is understand your claims data. This is so fundamental. If you had a data partner like Springbuk relying on your TPA is insufficient at best, and we've seen that from firsthand experience.

You can't fix a problem that you don't understand. The second is target your efforts. So once you've analyzed that data, you can decide where to invest and you may not be able to reach every cancer case. And guess what? You actually don't even have to because most cancer costs are driven by a small number of cases.

The third is provide case management for at least your highest complexity cancer cases. You as an employer are spending a ton of money on those highest complexity cases. Make sure that those dollars are going toward receiving optimal care because suboptimal care is actually really expensive. The fourth is catch cancers in early stages.

Emphasize the power of screenings. Emphasize the power of early detection. There are a lot of new early detection technologies out there, or coming out quickly on the heels of grail, for example. And so there's a lot of opportunity to catch cancers in earlier stages. The fifth is embrace precision medicine and the use of molecular diagnostics, the cost of an imprecise diagnosis is very high and it's much higher than the cost of that molecular diagnostic. And the last one is something that the Springbuk EHT report called out, which is steering employees to high value provider settings can actually impact a really significant share of your costs. So Springbuk particularly mentioned Keytruda administration being much more expensive in the hospital setting compared to the office setting.

Steerage can make a big difference as well.

Mike
Thank you. That's very helpful and I know throughout our episode today, there have been a lot of key takeaways and great nuggets for our listeners to take back with them and put into practice. Just thinking through this and not trying to add to the list of things for them to, count through, but what would you say are three things overall that you would want our guests to take away from this episode?

Natalya
So the first one is that cancer is complex, right? It's not one disease, it's many diseases, and it does require a robust and sophisticated solution to address it.The second is that there is something you can do as an employer to reduce the cancer burden in your population. And the last one is, there are power in two things. There's power in data and there's power in precision medicine and better care costs less.

Mike
Great. Thank you. So just thinking through this a, as folks are listening to this episode, if they wanna learn more about your background or connect with PHM in general, what's the best way for folks to, to connect with you and get in touch?

Natalya
Yeah, so if you wanna connect with Private Health, PHM, you can go to our website at privatehealth.com, and if you wanna get in touch with me, you can send me a LinkedIn message.

Mike
Perfect. Well, Natalya, thank you so much for joining, and thank you for contributing to the Employee Health Trends Report this year.

Natalya
Thank you for having me.

Mike
Well, that's it for this episode of Healthcare On the Rocks: Employee Benefits with a Twist. Remember to get your copy of the in-depth Employee Health Trends report at Springbuk.com/eht23.

On that webpage, you'll also find links to a recent webinar with the Springbuk authors of the report, as well as other related resources.

Jennifer
And finally, before you go, we would really appreciate if you would take a minute to leave us a five star rating or review for your on your favorite podcast platform. And thanks for listening. Until next time, cheers.

Mike
Cheers.

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