Closing Gaps in Cancer Care with Harlan Levine, President of Health Innovation and Policy at City of Hope

[00:00:01] Hey, everybody, Saul Marquez with the Health Matters podcast. I want to welcome you back to another episode recorded from the Health 2023 Conference in Las Vegas. Today, I have the privilege of hosting Dr. Harlan Levine.

[00:00:24] He is President of Health Innovation and Policy at City of Hope, a National Cancer Institute designated comprehensive cancer care center. He also serves as the chair of the board of Access Hope, a spin out company from City

[00:00:39] of Hope that is focused on serving the employer market and making leading edge cancer care available to all regardless of geographic location. So excited to have you on the podcast, Dr. Levine, appreciate you joining us. Dr. Levine I saw great to be here. Please call me Harlan.

[00:00:55] Dr. Marquez That sounds good, Harlan. That sounds great. Well, look, really excited to dive into the work that you and the team at City of Hope are up to. So to begin the discussion, Harlan, I'd love to learn what got you started in health care innovation?

[00:01:09] Dr. Levine Well, I would say it was an evolutionary process. I started in practice in the 80s and 90s, and I found myself compelled to be fixing the problems of health care.

[00:01:20] But all I could do as a sort of a single physician was put band-aids on a problem. So I started to focus on transformation and thinking about how to redefine the care delivery and ecosystem of health care.

[00:01:32] But with all the challenges we're having, affordability and disparities, quality of care variability, and more recently MD burnout, it's clear to me we need disruption. So I've been focusing on disruptive innovation, and now we have the science, the technology

[00:01:47] and the data to make the disruptive changes that we need. I'd like to paraphrase Wayne Gresky once said about skating to where the puck is going. It's not really enough to anticipate where the puck is going.

[00:02:00] We really have to innovate and redirect the puck if we want to improve health care. Dr. Levine That's a really great way to say it. It's no longer enough to skate where the puck is going. You have to redirect the puck in health care.

[00:02:14] And I love how you stated that, Dr. Levine. What is the most unique way your organization adds value to health systems and patients? Dr. Levine Well, Sal, there are several areas I'd like to highlight.

[00:02:25] So first of all, City of Hope is in fact indeed and known for being a leading edge research and treatment center. But we have from the very beginning of our roots 110 years ago combined that with a very

[00:02:38] patient centered and highly compassionate care approach to the patient and the family. So we're really a unique blend, I would say, of academia and patient focus. Over the last 10 years, we've grown and expanded into our local community in Southern California.

[00:02:53] And again, what's unique there is you've done it with a single faculty. So you get the same level of physician care in our main campus as you do in our community sites. Another action that we took that was I think unique is that we purchased Cancer Treatment

[00:03:08] Centers of America. So we now have sites in three new markets, Phoenix, Chicago and Atlanta. And what's unique about that is these are cancer hospitals that are now coming under the academic umbrella of City of Hope.

[00:03:23] And we're able to bring in our industry leading bone marrow transplant and cell-based therapy, but also a clinical research trial making the academic expertise of City of Hope available in a community setting in three new areas. Several years ago, we acquired TGen, which is a leading genomics institute.

[00:03:40] And this has allowed us to really bring precision medicine more quickly to the patient. The institute is busy identifying new targets for diagnostics and treatment. And we've been able to bring that in to our treatment centers for adding insights into how we take care of our patients.

[00:03:58] Three other quick things I'll mention. We're about to launch a mobile van, which we believe is the most advanced prevention and screening mobile van affiliated with an academic center in the country. And we'll be able to bring that into underrepresented markets. You mentioned Access Hope recently.

[00:04:16] We created a company and then spun that out so we're able to share our expertise even in markets where we have no physical presence. And lastly, we've been very active in policy trying to make care more equitable and accessible to all populations.

[00:04:31] So let's talk more about access to optimal cancer care. When we look closely at health equity, what are some of the barriers that separate patients from accessing the latest breakthroughs and advancement in cancer treatment? And why do those barriers exist? Yeah, that's a really important question.

[00:04:49] We feel like it needs to get more emphasis. We are living in one of the most transformative times in cancer where there's been a dramatic decrease in mortality rate, but the access to these great discoveries are not equally distributed.

[00:05:05] I mean, think about the improvement we've had in genomics and being able to more clearly define the cause of a cancer, which then leads to more targeted therapy. But it's also surgical enhancements. So many patients are getting left behind.

[00:05:20] So in answer to your question, we know that social determinants of health are really important here. So there's a cost of care and even care that goes outside of one's benefit coverage. People have issues with transportation, trust in the healthcare system.

[00:05:36] We know that zip code will influence outcome. The distance from an NCI center will influence the mortality rate. And then the local environment, like access to healthy food. So nutrition plays a big role, but also the system is not great at creating culturally

[00:05:53] appropriate education so people understand how to prevent and manage their cancer. And this leads to really significant outcomes. In California, a study was done that showed that fewer than 50% of Californians receive care that's up to standard of the NCCN guidelines, the National Cancer Center Network guidelines,

[00:06:14] which are really the gold standard. And this is much worse in underrepresented communities. Another study demonstrated or reflected that one in three cancer deaths for people between the ages of 25 and 74 can be avoided if we address the socioeconomic issues and disparities that exist today.

[00:06:33] Again, focusing on a real tangible impact of this, African American men die at twice the rate of their white counterparts from prostate cancer. And African American women die at 39% higher rate than their white counterparts in breast cancer.

[00:06:51] Hispanic women who have a higher incidence of stomach cancer are also diagnosed at a later stage and have twice the death rate from stomach cancer. So these are real issues and social determinants of health are clearly important.

[00:07:05] I personally focus on issues that relate to the complexity of our health system, which I believe also exacerbate these issues. Let me give you one example. It is a very common tool under the umbrella of value-based care to deploy what we call a narrow network.

[00:07:24] This is where you limit the number of physicians that you could see, mostly to drive economic advantage for the health plan. And this makes sense for so many other conditions where expertise is abundant.

[00:07:36] But in cancer, you have an issue where the information is coming so fast and furious, it's almost impossible if you're not a subspecialist to keep up with everything. With genomics, cancer, instead of just being a handful of conditions, is now hundreds of

[00:07:54] different conditions, each one defined by its DNA blueprint. So if you can't keep up and the physician network is self-reporting that they are not confident that they are keeping up with all the evolution, when you start to narrow the

[00:08:09] network by definition, you're limiting access to subspecialization that's so important. So here's an example of where with good intentions to drive affordability, a narrow network just doesn't work in the cancer population. And we know that there are a disproportionate number of people of color and those from underrepresented

[00:08:31] communities in these narrow network insurance products. So again, they are disproportionately affected by this lack of access to the expertise that's needed. HOFFMAN. Definitely those determinants of health and the complexities can really benefit from value-based care. Love the discussion here, Harlan.

[00:08:51] Is there any evidence of the impact of narrow networks? DAVID KAPLAN. Yeah, there's a lot of evidence of impact. I'll just mention two. In Medicare Advantage, which by the way, I support Medicare Advantage and it's done great things for prevention and early detection and primary care.

[00:09:09] But in Medicare Advantage, the networks have far fewer inclusion of NCI centers, academic that are certified by the Commission on Cancer. And I think this has impact, particularly with more complex cancers. Take for example, complex surgery on stomach or liver cancer where the death rate from

[00:09:34] the 30-day mortality rate from complex surgery on those organs is 50% higher in Medicare Advantage than it is in traditional Medicare, which has open access to these centers that I mentioned. For pancreatic cancer, the 30-day mortality rate is 100% higher.

[00:09:54] You are twice as likely to die from pancreatic surgery if you are a beneficiary of Medicare Advantage plan. So that's one example. I think the other example is that in subtle ways, if your network doesn't include access

[00:10:09] to these academic centers, you're not going to know about and you're less likely to get advanced therapies such as cell-based therapies by specific T-cell engagers. And the tangible data point behind that is we know that 15% of cancer patients in this

[00:10:26] country are African American, but only 4-6% of patients on clinical trials are African American. And to me, that tells us two things. One is they don't have equal access to the academic centers. And two, if we're not studying these subpopulations, we're going to perpetuate this pattern of

[00:10:47] not knowing how to optimally treat these populations of people who are color or from lower socioeconomic environments. So we'll just continue this cycle of less than equitable care for all populations in the country. HOFFMAN Wow, some really great points there.

[00:11:02] What are some examples of solutions we can offer that would eliminate the barriers to innovation and improve cancer care access and equity? KUZNICK There's several categories where we can help with equitable access. So one is I already talked about our expansion.

[00:11:18] City of Hope is expanding into markets that are underrepresented so we can bring our NCI level of care into these communities. And you also mentioned Access Hope earlier. Access Hope is an entity that is a company that we spun out where we're actually delivering

[00:11:36] expert opinions through the employer to people with cancer who otherwise would not have access to leading edge information. So we're able to offer the expertise of a subspecialist from an NCI center and we've now spun this out into a company.

[00:11:54] We've been joined by multiple other NCI centers including Dana-Farber and Northwestern, Emory, Fred Hutchinson Cancer Center in Seattle and most recently Johns Hopkins all providing these second opinions not only to the patient but to the provider, the community doctor

[00:12:12] so we can close that knowledge gap that might exist because of the speed with which things change. And because of the design of the program whether you work in the boardroom or you work in the mailroom you now have equal access to this NCI level expertise.

[00:12:29] We're also focused on policy changes. We formed a coalition several years ago, a multi-stakeholder coalition of people concerned about having equitable access in cancer care. We called it the Cancer Care is Different Coalition and this coalition helped us promote first

[00:12:45] a resolution in California that was the first of its kind cancer patient bill of rights that identified rights that patients had to speedy care, culturally sensitive care, access to expertise. We were then challenged by the California legislature to make this more of an obligation

[00:13:03] so with the help of key champions in the legislature we helped to draft the bill that became the California Cancer Care Equity Act which specifically says for patients with complex cancers that were defined if your network doesn't provide the expertise needed then you have the right

[00:13:21] to seek that care from an academic center that does have the expertise for that type of cancer and the health plan has the affirmative obligation to let people know. We think that's a really sentinel moment of change, deflection point and we also have

[00:13:36] a vision now to bring that on the federal level again addressing Medicare Advantage helping them understand that they need to modernize their definition of network adequacy to keep up with the speed of progress and innovation occurring in cancer. HOFFMAN Thank you so much.

[00:13:52] Yeah, there's a lot of ways to overcome those barriers, collaboration, technology and a lot of those examples you shared are really inspiring. As we look into the future and work toward closing these gaps in access to optimal care

[00:14:06] what does the ideal future of health equity look like in your eyes? KUHN Well in my mind to create an ideal vision for the future one needs to start with the patient and how they view the system.

[00:14:17] Let me give you a quick example of a patient who's agreed to be identified and tell her story. It was at the time of diagnosis a 29-year-old woman by the name of Koma and she had a painful

[00:14:31] mass in her right breast and for months her primary care doctor told her she was too young to have cancer but they were wrong and by the time diagnosis was done she was diagnosed with a stage 4 triple negative inflammatory breast disease which is the most aggressive

[00:14:47] you can have. And her initial oncologist told her to basically put her affairs in order that nothing could get done but she didn't settle for that and she found her way to City of Hope where she

[00:14:58] did get treated and just to fast forward she married the man that she was engaged to at the time and she went on to have a beautiful child now has a great family. But here's the point a patient with cancer shouldn't have to fight the system the system

[00:15:13] should wrap their arms around the patient. We need to create a system where the community and the academic oncologists are working together and identifying the level of expertise that needed that's best for the patient whether it's advanced treatment or perhaps a clinical trial.

[00:15:31] I'll just add a couple more thoughts. This connection between an academic center and a community oncologist is even more needed in underrepresented communities and what I'd like to do is instead of having the system pit community oncologists against academic physicians rather create an ecosystem where

[00:15:51] they're integrated and working together. The other point I'll make again from the patient point of view is that patients need supportive care throughout this process and we shouldn't leave that out that there's a huge emotional

[00:16:03] toll and social toll and that if we're not addressing those for the patient and the family oftentimes care will be sub optimized. Now I know that it'll take time to develop that but at this conference we keep talking about how to redesign health care.

[00:16:19] If we don't take into account the patient perspective the patient value their priority on survival on the care experience they were very unlikely to design a program that really meets their needs. Perhaps we ought to focus on patient value and health equity first and then we can on

[00:16:36] a more stable infrastructure we can then work on affordability. And so I'll point out that the employers already are having their voices heard and they are demanding this. We talked about access hope before.

[00:16:52] I just want to let you know that in addition to all the NCI centers that have joined us we also have 150 employer customers 36 from the Fortune 500 that have engaged access hope. At this point access hope is now covering 5 million members and the point here is people

[00:17:10] recognize that this expertise is needed and we need to find a way to get it into the community. Well certainly a future to aspire to and it looks more realistic with the work that you and the team are up to at City of Hope.

[00:17:24] Can you share a closing thought Dr. Levine and where listeners can get in touch. Yes well thank you Saul for the time. I guess my closing thoughts would be let's build a system that reflects society's values.

[00:17:38] I've had the privilege of working with some of the best researchers and clinicians in the business and I feel obligation not only to help City of Hope succeed but to change the system to make it more equitable.

[00:17:51] Today having health coverage does not equal having health access and you know with all the challenges that are occurring out there it's no longer enough just to anticipate where the puck is going but we need to redirect that puck that we mentioned earlier.

[00:18:07] Everyone should have the ability to have access to the amazing innovation that's led to life saving therapies and I think we need to reinvent the ecosystem so community oncologists and academic oncologists both important pillars of the oncology ecosystem that they're working

[00:18:25] together so information is flowing more quickly between the two and I think once you make that connection you'll be able to better land the patient in the location that would lead to the best outcome for them overall. Thank you so much.

[00:18:40] This has been an incredible episode and folks remember health matters and it matters in a way that includes health equity and access and the work that the team at City of Hope are doing to make it possible is making health matter for more Americans and people worldwide.

[00:18:59] Can't thank you guys enough for being with us today. Thank you, Saul.