Disparities of care that result in poorer outcomes among certain populations have long been an issue addressed by the cancer community and its major organizations such as ASCO. While ethnicity and race play key roles in this ongoing debate over equitable allocation of our precious health-care resources, another persistent issue frames the larger story of the haves and have-nots in cancer care outcomes: poverty and the politics of health-care distribution.
To bring clarity to the issue of how we apportion health-care services and the doctors who deliver them, The ASCO Post visited with Richard “Buz” Cooper, MD, Director of the Center for the Future of the Healthcare Workforce and a Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania. At the Upper East Side apartment he shares with his wife, Barrie R. Cassileth, MS, PhD, the Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan Kettering Cancer Center, Dr. Cooper shared his experiences in hematology and oncology, as well as his current work in public health.
Early Career
With the Manhattan skyline stretching out from the 32nd-floor apartment, Dr. Cooper, a tall man with a professorial bearing, explained that his early career as a hematologist was influenced by his work at the National Cancer Institute (NCI) in 1963, when Drs. Emil Frei and Emil J. Freireich first began using combination chemotherapy to treat childhood acute leukemia. “It was an extraordinary experience to see these children with a heretofore fatal disease respond to this first-time-ever treatment. It was truly a remarkable time in oncology, and I wanted to be part of it,” said Dr. Cooper.
After his stint at the NCI came to a close, Dr. Cooper finished his hematology fellowship at Boston City Hospital. In 1971, he went to the University of Pennsylvania to start a hematology/oncology program. “Interest was building to expand the nation’s cancer centers, so we gathered our resources and developed a cancer center attached to the university, which broke the mold of the freestanding centers that the NCI preferred,” said Dr. Cooper. He added, “Dr. Peter Nowell, who discovered the Philadelphia chromosome, assumed the director’s mantle for the first years; then I took over, and we developed the center into a nationally recognized multidisciplinary cancer institute.”
The next chapter in Dr. Cooper’s career took him back to his hometown of Milwaukee, where he became Dean of the Medical College of Wisconsin. “It was a small school that struggled financially. Much like the Penn cancer center, which we really made out of whole cloth, the Medical College, in a sense, had to be built from the ground up. It was a 9-year project of love, and when I left the College it was on the cusp of being a powerhouse,” said Dr. Cooper.
Physician Supply and Demand
The next period of Dr. Cooper’s career was transformative and, in part, informs his current work in public health. During the Clinton administration’s health-reform initiative, a startling observation emerged: We were heading for a surplus of 100,000 doctors by 2000. According to Dr. Cooper, this projection would reduce the recruiting of students into medical school and drastically cut residency programs, causing long-term reductions in America’s physician force.
“This doctor surplus dogma was held by many experts. A friend of mine at the [American Medical Association] asked if I could address this issue. I did, and I soon found a glaring error in the surplus projection: Their conclusion was based on outdated census data, which assumed that the U.S. population was not going to increase. So, I called the Census Bureau and had them send me the current data,” said Dr. Cooper.
Dr. Cooper applied the Census Bureau’s updated projection of population growth with the existing projections of physician growth based on the numbers coming out of medical schools, currently working, and those retiring.
“The administration’s projection of a surplus of doctors by 2000 was wrong. Instead, we were on track for a dangerous shortage of doctors,” said Dr. Cooper. “My findings caused an outrage. But there were nuances that the administration was missing. For instance, at one point, lung cancer was virtually untreatable so of course you didn’t need lung cancer specialists. But advances in detection and treatment fostered a need for more oncologists to treat that and other diseases. We needed more doctors, not fewer.”
In 2009, Dr. Cooper was called to testify at a Senate hearing on the need for innovative models in health care, which was, in part, a subtle call for a reduction in physician services. During the hearing, Dr. Cooper made his opinion clear: “My analysis of our need to expand physician supply and encourage innovation in physician practices stands against a set of beliefs that more physicians and more health care may not be good for the nation…. In fact, the preponderance of data do not support these conclusions.”
To this day, Dr. Cooper laments that after all his work on the issue of physician supply and demand, there was still a core of influential policymakers who favored a reduction in the number of physicians. “I have an upcoming debate at the National Resident Matching Program, but the fact that I’m arguing whether or not we need to expand physician supply is sad. There is an entrenched body of opinion in certain sectors of health care that refuses to recognize, for instance, that we are facing a workforce shortage crisis in oncology,” he said.
Health-Care Disparities
Dr. Cooper further commented that along with the erroneous statistics used to project a surplus of physicians, the government-driven agenda was claiming that addressing waste and inefficiency would ameliorate the need for more doctors and services.
“The fundamental underpinning of this grand assumption is derived from The Dartmouth Atlas of Health Care, which contends that regional variations in cost are driven by variations in how physicians practice,” he said. Although Dr. Cooper agrees that there is substantial waste and inefficiency in the health-care system, he contends that it is economic disparity in care, and not physician practice patterns, that drive overutilization of health-care services.
He stressed that poorer people, for a number of socioeconomic reasons, are less healthy than economically stable or affluent people and therefore cost more to treat. “For example,” he said, “Mississippi, which is the poorest state in the country, has very high per capita Medicare spending, simply because the population presents with serious health issues that are costly to treat.”
Dr. Cooper emphasized his point: “Health-care costs on the affluent Upper East Side of New York are about 80% of the national average. But walk a few blocks up to Harlem, for instance, and the per capita costs are about three times the national average. The same health-care providers are serving patients from both areas, but the patients from Harlem simply cost more to care for because of the negative health consequences of living in poverty. And if you merge the data from the two economically divergent areas, you get a very distorted view of costs relative to physician services in Manhattan.”
In Dr. Cooper’s opinion, projects like The Dartmouth Atlas and other cost-effectiveness initiatives that ostensibly seek to decrease waste and inefficiency in our health-care system have an unintended consequence—they erode physician autonomy and move the locus of control from the medical professional to the regulators and health-care administrators.
“All of these academic conclusions about overutilization of physician services being the main driver of our so-called fiscal crisis in health-care point at specialties, such as oncology, as the main cause. However, it is just the opposite; specialists drive innovation and excellent, cost-effective care.”
He continued, “In fact, when all of the states across the country are critically examined, more total spending and more specialists are associated with better-quality health outcomes—just the opposite of The Dartmouth Atlas message, but just what you would expect if you analyze how the delivery of health-care services truly affects populations of vastly different socioeconomic structures. Furthermore, more spending at the high end improves outcomes because the care consists of a broader spectrum of beneficial services.”
Poverty and Health-Care Costs
“There is a small group of researchers who generally get lumped into the “social justice world” of medicine. They’re a good bunch of professionals who have collected abundant evidence showing that poverty is strongly associated with poor health status, greater per capita spending, more hospital readmissions, and poorer outcomes. It is the single strongest factor in geographic variations in health care and the single greatest contributor to excess spending,” said Dr. Cooper.
He stressed that in order to fully understand how different populations access health care and utilize services, we must develop a risk-assessment methodology that captures all of the social and demographic variables. “A new report by the [Institute of Medicine] has recommended such an approach. It will be difficult to implement over time, given the complexity of these variables, but at least it points us in the right direction and blows the whistle on those policymakers who slice and dice the data to arrive at politically expedient conclusions,” said Dr. Cooper.
Dr. Cooper is a firm believer that more doctors—especially oncologists and other specialists—are ultimately needed to deliver high-quality cost-effective medical care as our aging population grows. He also is firm about another subject: Poverty is a huge driver of health-care costs. To that end, Dr. Cooper is working on the last chapter of a soon-to-be-published book titled Cancer Through the Lens of Poverty. ■
Disclosure: Dr. Cooper reported no potential conflicts of interest.
