Treating the whole patient at CTCA

Show Notes

Daniel sits down with Dr. Pat Basu, President & CEO of Cancer Treatment Centers of America, to discuss his unique point of view on the evolution of oncology care, precision medicine, the changing role of MD MBAs like himself, his early telemedicine work with Doctor On Demand, as well as his time as a Fellow advising the White House.

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Pat Besu:
The best cure is definitely prevention. And I tell the story that I got from my White House days of there's two providers, and a bunch of patients are downstream in the river, and they're pulling them out, and one of them runs up, and the other doctor says, "Where are you going?" He says, "I'm going up to tell them to stop jumping into the waterfall in the first place."

Daniel Kraft:
Hi, I'm Dr. Daniel Kraft. Welcome to Healthy Conversations. Today we're fortunate to be in healthy conversations with Dr. Pat Besu. He is the president and CEO of Cancer Treatment Centers of America. You've broached many fields from telemedicine now to the cancer world. When I was going to medical school, no one got an MBA. And when you maybe speak to, let's say MD MBA students of today, how do you help them understand the potentials a physician after medical school can do?

Pat Besu:
I do sometimes joke that I'm certainly still trying to figure out what I want to be when I grow up, in the sense of medicine, and business, and policy. But I do tell them to not be afraid, to be interdisciplinary, to really expand their horizons, and cross different paths. If you want to solve grand challenges, they're not just in biology, they're not just in chemistry, they're not just in physiology. They're taking disciplines and putting them together. You had to maybe invent your own space and probably deal with a little bit more of a skewed look from a attending physician who would say, "Wait a second, why are you going to work at the White House?"

Daniel Kraft:
Yeah. I'm really curious about, you had this amazing opportunity to be a White House fellow and senior advisor.

Pat Besu:
Absolutely. A ton of takeaways. And just the concept of the American dream is one that, as a son of immigrants, burns very passionately in me. The country, being at a crossroads, I think there's a lot of danger in misinformation, disinformation. The war on facts, and data, and science, is one of the greatest concerns. I think the role of physicians has really broadened.
At the White House, there was a training session, and it was a bunch of us preparing for a national emergency. This particular case happened to be a pandemic. And within reason, I think a bunch of us looked at it, and said, "Well, it's probably not as likely as the hurricane, or the military conflict, or the things like that." But obviously, we took it very, very seriously. We planned through that. And sadly, that came to clear fruition 10 years ago. The reason I mentioned that is, when I worked at the White House, I think I was one of maybe a couple of doctors that were there. I just am a big advocate that doctors should be involved, and frankly that places like the White House, and the US government, should look to bring doctors in.

Daniel Kraft:
Speaking of the changes around COVID, since it's been such a up and to the right element, telehealth, and you are intimately involved in Doctors on Demand, can you share a little bit of that experience?

Pat Besu:
It's just been great for me, not just personally, to see my baby, Doctor on Demand, make such a big impact, and grow, and go from hundreds of thousands of visits to millions, and the impact that causes. I think it was Victor Hugo who said that even the greatest army can't stop an idea whose time has arrived. And it just makes sense. It makes sense for patients, it makes sense for providers, it makes sense for the American healthcare system. Digital medicine is going to continue to change health care. And I think virtual telehealth visits are just at the beginning.

Daniel Kraft:
Part of the challenge often is enabling the clinicians of today, who may have graduated medical school 10, 20, 40 years ago in some cases, to keep up with some of these emerging platforms, whether it's telemedicine, or a digiceutical. No one's really wedded to the fax machine, but we may be wedded to old processes and old mindset. So, how do you see the current medical culture today? How's it evolving?

Pat Besu:
With respect to physician cultures, and maybe barriers to some tech innovations, there's a little bit of a, I'm going to call it a good, a bad, and an ugly, maybe. So, I think the good is there's sometimes a, "Hey, listen, before we innovate too fast, I want to make sure that this is safe for my patients," which is wonderful and always needs to be the Hippocratic Oath.
I think the bad in physician barriers to innovation is just some of the experiences. You look at EHR or the EMR, as you know, Daniel, is the only sector that in the last 30 years has had decreased productivity. You look at the EMR and a lot of physicians are scarred by that. This was supposed to make life more efficient and now it's actually made, in many cases, life worse. Oftentimes, people have thought about the user experience of the consumer while not thinking about the user experience of the physician.
And then, of course, there's an ugly, these are some states that have really bad access to health care, really poor access to quality health care, and that fiefdom could be interrupted or competed against was concerning to them. There's also a consumer behavior change. If you told most people that, when they're in flight, that the computer, the autopilot, is doing a lot of that work, it would probably freak them out. But patients sometimes they don't realize that, wait, how are you going to take these vital signs? So, there's an education in the consumer side that also needs to occur, and that can sometimes be as important to accelerating good innovation as the physician side.

Daniel Kraft:
And so, I imagine that might be influencing your experience now leading Cancer Treatment Centers of America where, in cancer, and I'm a pediatric oncologist by training, there's a ton of data.

Pat Besu:
In fact, Daniel, the reason I took this job is, as you and I have discussed, is I'm a big believer in building a better America, a better American healthcare system. And in many ways cancer is the tip of the spear of all of those things. It represents the best of American health care in its innovation, and its experimentation, and it's pushing the frontier, we should say. But at the same time, American health care is fragmented. It's expensive. It's hard for the consumer to understand. And if you think about the aspects of telehealth, in Doctor on Demand's initial forays into urgent care and behavioral medicine, you're not going to, in the year 2021, replace that infusion, that chemotherapy, that immunotherapy, that radiation therapy is needed, that surgery is needed, but it forms as a wonderful bridge to care. In our case, where we see patients from all over the country, it can allow us to stay in good touch and care manage those patients. Our founder's mother sadly passed from cancer. And he built this company on the very notion of patient empowerment and that patients have a voice.
One of the things I love about Cancer Treatment Centers of America is we treat the patient holistically. So, there is nutrition with dieticians and behavioral therapy in addition to medical, surgical, radiation therapy. A lot of those things can be packaged virtually, but I wouldn't be myself if I didn't talk about areas for improvement. When I arrived here, we were majority out of network. You can't have a great outcome or a great solution if people can't access it. And we're now essentially all in network and even working towards value-based care.

Daniel Kraft:
I'm probably asked every couple weeks, where should I send this patient with X form of malignancy? Is there some power to your scale and the data instead of the shared learning that is within CTCA? And maybe are you able to start to bridge that to other academic and community oncologists?

Pat Besu:
Definitely. Definitely. We're an escalation pathway. We know we can't be the best at everything, so can we partner with community hospitals? Can we partner with physician groups to make cancer care better for all patients, whether they come through our walls or not? And that starts with several things.
I once had a patient tell me, Daniel, "I fought the cancer so hard that finally the cancer gave up before I did." And I thought about that, and I said, "Geez, what a powerful statement." And I realized that sometimes it's just, with some of the side effects, you need to keep that patient's mind engaged and their family's minds engaged, and that's where things that we might do that others might have frowned at, like helping them pick out their wig to a sexual side effect counselor, we're helping other providers with those things. Our goal is to eliminate cancer from the face of the earth for sure. Definitely to try and get a solution that might otherwise be discovered by ourselves in 2030 is not good enough. If somebody else can help us get there in 2021 or 2022, then we want to partner with them.

Daniel Kraft:
Yeah, a hundred percent. And speaking of trying to make cancer history, part of that is detecting, number one, preventing it, but also picking it up early. I always like to call it stage zero. Just a side point back to the pandemic, it really put a dent on standard screenings, colonoscopies, mammograms.

Pat Besu:
Yeah, you're spot on. The best cure is definitely prevention. I tell the story that I got from my White House days of there's two providers and a bunch of patients are downstream in the river and they're pulling them out, and one of them runs up, and the other doctor says, "Where are you going?" He says, "I'm going up to tell them to stop jumping into the waterfall in the first place." I'd say 30 years ago, if you ask people, can you prevent heart disease? Not many people have raised their hands. You ask people now, and they say there's all sorts of things. There's statistics that show 50% of cancers are potentially preventable through lifestyle modifications, number one. Number two, absolutely, with screening and early detection, for every cancer type, as you know, better outcomes, and frankly to the patient and to the system, far lower cost of treatment if you catch something earlier. As it is, we as a society, we're missing the mark.
The pandemic made that worse. It made the health disparities worse. There were times, Daniel, during the pandemic, where 80%, 90% of mammograms, colonoscopies, pap smears were being missed. And there were estimates that showed that tens of thousands of cancer diagnoses were likely missed or delayed during the pandemic. Patients want to do the right thing. But how do you, using design thinking, make it so seamless and so easy that you take away all friction, and particularly for health disparities? Black men with the propensity for lung cancer are disproportionately not getting their screening imaging. Across the board for breast cancer, for Black and Brown women, there are major disparities in health care. In rural America, and again, this is not just a racial thing, in white rural America, there are patients who are not getting appropriate access to screening and proper care. That needs to be our mission. It is definitely one of our missions at Cancer Treatment Centers of America.

Daniel Kraft:
What's most exciting and where do you see, let's say, the next decade going in oncology care?

Pat Besu:
I think precision medicine is just incredibly exciting. Just the idea that patients might respond differently with an almost infinite permutation of factors in their genetic condition, in the genomics of the tumor, in the way that they respond to various medications. When we were studying cancer types, there might have been 15 different cancer types, but now there's 15,000. And now, you're treating a specific mutation. And it's a huge area where we partner with phenomenal companies around the country to really just find for a specific patient. I really think that five to seven years from now, every patient is going to come in, have a personalized profile that truly optimizes, even if it's one or two percentage points, the best regimen for them versus somebody else.

Daniel Kraft:
Still, often one size fits all. It's lung cancer, it's a lymphoma, you get the standard CHOP chemotherapy. But the future is this multiomics from the changing genome of the cancer or its subtypes, or the cancer stem cells to the microbiome of the patient, to all the other metabolic markers. I think the ability to synthesize that and drive targeted therapy, as you mentioned, which maybe half a million dollars in today's world, that again, can't scale to thousands or millions of patients. So, hopefully these things will come down, like the price of cell phones and other technologies, but they probably won't ever get fully digitized.

Pat Besu:
I think about it a lot. What telehealth did to traditional medicine is expanded the barriers of space and time. You weren't just getting care in this county in Mississippi on this particular day. You now had access to doctors all over, all the time. Insurance is bounded at a finite geographic level. Oftentimes still, even with the exchange, is oftentimes tied to an employer, usually measured in one year horizons. So, if you are a "risk-bearing entity," whether that is a state government, a federal government, a private insurer, or a at-risk provider, one of the things that stops you from making long-term investments is you're afraid of churn at a year. And you and I know, even in oncology, boy, your return on that investment, meaning literally saving a life, might not actually occur in that calendar year. If that covered life, so to speak, switches in that time, then it forces those risk-bearing entities oftentimes to have perverse incentives.
So, we need to change that. We need to be able to say somebody is truly covered for an extended period of time where that curve can catch up. But ultimately, we really have to figure this out, because oncology is amongst the... Well, it's the number one cause of the medical areas of causing medical bankruptcy, a top three cause of medical spend. To me, the simple equation is, are you getting health care return on that investment? But it's one that needs to be addressed, especially in the era of precision medicine where you just cannot finance one size fits all.

Daniel Kraft:
Right. Sometimes you get what you measure or you incentivize. You might be measuring just tumor size or months of life. That may not be the actual quality measure that's important to the patient, or the caregiver, or the payer. In terms of adoption, how do you incentivize better adoption within your own organization, or more broadly in health care, whether it's telemedicine, or a digital therapeutic, or a mental health platform or a new immunotherapy?

Pat Besu:
Great question. I learned a ton in my time in the Bay Area and Silicon Valley and building Doctor on Demand on the notion of user experience and user interface. For a doctor on an EMR, it feels like it takes them 10 minutes just to figure out how they change the order set. So, really focusing on physician user experience, on physician user interface, I think just has been a... It's not even a lost art, it's just been a non-existent art. I know our doctors, and certainly most doctors who go into medicine are in it for better patient care. So, when we're able to truly show that this actually makes things better for the patient, then physicians are able to say, "Oh, okay. This is something I really want to accelerate or champion."

Daniel Kraft:
It often seems to be about lowering the barriers.

Pat Besu:
I always say it's cancer care is a disease as much of the body as it is of the mind, and definition of a team sport where all those team members are so critical. Maybe I'll end where I began. I think less than 5% of CEOs were physicians. Less than 5% of healthcare entrepreneurs were physicians. Less than 5% of Congress were physicians. And having doctors involved with anything from the user experience to the economics, to the tech innovation side, it was just a way to make the world a better place, and frankly, to find great professional fulfillment at a time when I think physician satisfaction has gone down. And I would just encourage all your listeners to keep up the good fight, and I'm optimistic about it.

Daniel Kraft:
Thank you so much, Pat, for joining us in Healthy Conversations, and keep up the amazing work at Cancer Treatment Centers of America. And for anybody listening, the opportunity, no matter what realm of provider care or health care you're in, we all can see challenges and opportunities and can help solve them collaboratively. So, we'll see you next time.