You Plan Your Way to a Cancer Cure?
For 20 years or more, since my graduation
from business school, I have been involved in strategic planning. While there
are many books written about planning, to me defining it is rather simple
though doing it is not.
Strategic planning is a combination of what
and how; what business are you in and how do you design the manner in which you
will pursue that business to gain a competitive advantage in the marketplace.
In 1993, when I first went to work for
David Hohn, one of my earliest tasks was to guide the leadership of MD Anderson
through a strategic planning exercise. This was deemed to be necessary because
the new First Lady, Hillary Clinton, and 1000 of her closest friends were proposing
to completely revamp health care in the US using the forces of managed care and
managed competition that had been born in Jackson Hole, Wyoming. This was THE WAY
by which health care costs could be contained and quality rather than quantity
rewarded. In essence, the fear running through medicine was the proposed shift
in the manner of payment from fee-for-service, where the more you do the more
you make, to a capitated model of pre-payment for the care of many “covered
lives”. In the capitated model, the less you do the more you keep, presumably
because the docs have kept their patients healthy. Fee-for-service rewards a
full hospital. Capitation rewards an empty one. In essence, financial risk was
shifting from insurer to provider. Drs. Hohn and Balch were sufficiently
informed of the threat this posed to Anderson’s business model that they wished
to explore ways to secure MD Anderson from these threats. They wanted a plan.
Hohn and Balch were forward thinking. Way
too forward. Twenty years later, the United States is still largely in the
grips of the fee-for-service system of health care payment. Shortly after the
Hohn/Balch concerns were raised, then-Governor George W. Bush signed
legislation that allowed patients who previously had to be referred to Anderson
to self-refer. The patients and the money poured in. (Being DRG exempt as one
of the first cancer centers didn’t hurt either).
All thoughts of planning went out the window
as unnecessary. Capitation and managed care by-passed Texas. MD Anderson was
rolling in dough without the need for any planning, strategic or otherwise.
Today, the new world order looms.
Fee-for-service is still the predominant
form of payment for health care, but the payers, the government and the
insurers, are more powerful than ever. They are all seeking ways to hold down
reimbursement at the same time that academic medicine specifically and medicine
in general have overbuilt and in many cases over-hired primarily because work
that could be done by computers in most industries is not yet being
electronically done in medicine. Medicine is not yet ready for machine-based
interactivity to collect data, exchange it and use it for decision support and
rapid and accurate reimbursement. People still run health care. Just not
Too late, the physicians and other care
providers have come to the conclusion that they have been marginalized in the
business of medicine, tossed aside like so much dross by the insurers, big
pharma and the huge hospital organizations, as well as the federal government.
That government is probably paying for half of the health care in the country
(Medicare, Medicaid, the VA, the military, the Indian Health Service). Exactly
what market forces are those Republicans invoking as being the savior of health
The scapegoating of ObamaCare as the source
of all evil for doctors is pure crap as well. The economic forces that have
begun to curtail physician income as well as the forces creating more and more
cardiologists and an inadequate number of primary care providers (for example,
huge medical school debt), were in place and ramped up long before the
President signed a piece of legislation in 2010 that is falling by the wayside
piece by piece each day, like construction material out of a pick-up truck on
the Loop. The 30-34 million who were supposed to gain coverage under the ACA is
probably closer to 15-17 million and even the Congressional Budget Office
projects a diminution in work hours caused by the implementation of the ACA.
This is due to workers figuring that they can become even more dependent on
government subsidies to gain their health insurance at a lower price if they
make less money as their lower wages qualify them for government subsidies to
pay for health insurance. Some have calculated they could work less, spend more
time with their kids and still come out ahead. I guess that worked out poorly.
I think that I can say as I look back at my 20
year planning experience that this has not gone as planned, precisely because
there was no plan for MD Anderson or for medicine in general. No plan, no
discipline. No discipline, no progress. No progress, no price increases. Since
costs always go up, especially when you are paying 19,000 people and supporting
a good bit of research that the NIH is no longer capable of financing, this has
put places like MD Anderson in a tough position.
Now Anderson is being presented with a new
strategic vision—the Moon Shots. I am not exactly sure how this raises money
(although I am quite sure I see how it COSTS money).
In all the strategic exercises I have been
part of, the various moving parts and vector forces with which any plan would
have to contend were either known or could be reasonably anticipated with some
sensitivity analysis placing error bars around likely occurrences.
There are some, like Dr. DePinho, who would
have you believe that we have arrived at a place in our pursuit of the cure for
cancer that would allow strategic planning for that inevitability. I think they
Given our track record in planning the
operations of a cancer hospital, I am not sure I would want any of that
leadership crew involved in my future, but I am absolutely sure I wouldn’t want
them involved in planning the pursuit of Making Cancer History. In fact. I
wouldn’t let anyone do that for we simply do not know enough to even plan such
a strategy. Rather we must continue to Braille our way through a morass of
genomics, proteomics, signaling pathways, new targets, as yet undescribed insights
in biochemistry and immunology as well as putting it all together in a comprehensive
cancer biology that leads to an in-depth and predictable model of
carcinogenesis, the resultant associated perturbations of normal microcellular
biology and a complete biochemical and genetic description of metastases.
I don’t think we are ready to plan a way to
Make Cancer History just yet. Of course, given the success to date, why start planning