Dr. Nathan Handley is an oncologist at the Sidney Kimmel Cancer Center at Thomas Jefferson University — and soon, he hopes, at a home near you. Handley believes that most cancer treatments do not require a hospital or endless trips to doctors’ offices. He argues that for most patients, being treated at home is just as safe, more affordable, and more convenient than in a clinical setting.
Freethink talked to Dr. Handley about his vision for how patient-centered care can improve the healthcare experience for everyone.
This interview has been condensed and edited for clarity.
Freethink: When we think about healthcare innovation, we imagine people in lab coats whipping up revolutionary miracle drugs. But that’s not what you’re doing. How do you think about improving healthcare?
Dr. Handley: When I was in medical school, I thought that the way to be influential and affect positive change in healthcare was “bench-to-bedside” research—bringing things from the lab to the patient.
But when I started residency, I was immediately struck by how inefficient the system is, and how many barriers to good healthcare are really structural and operational in nature and not necessarily related to the actual medicines. We have really good treatments for a lot of things —not perfect, and it’s important that we improve those too—but so much of the challenge in healthcare is really just getting the right care to the right patient at the right time.
Freethink: What are the biggest problems you’ve seen in how we deliver healthcare, specifically when it comes to cancer?
Dr. Handley: Cancer care is not only very costly to the health system but to patients as well.
Physicians see patients in a clinic for 15 minutes and say, “Okay, that was pretty easy.” But from the patient’s perspective, it’s not. They drive 45 minutes to get to the clinic, they park in a ramp that cost $20. They wait in a clinic. Usually the oncologist is running behind by 20 or 30 minutes or an hour. Then they see the oncologist and maybe they get an infusion later that day. What looks like a 15-minute appointment from the provider’s side is a whole day for the patient.
The implications of that are really significant in terms of the patient’s ability to live the rest of their life. If they have a job, then they have to take off work. There’s lost wages associated with that.
Freethink: How can we do better at delivering healthcare?
Dr. Handley: When I went to University of Pennsylvania for an oncology fellowship, I had become interested in understanding systems of care and how you effect change within complex systems. So I decided to get an MBA to learn about practical mechanisms by which to improve the system. That was when I came onto the idea of “hospital at home,” an idea that would bring us back to how care was delivered in the early 1900s when the physician went to the patient.
One of the opportunities with providing care in the home setting is that you flip that equation, so the value of the patient’s time increases significantly. Part of the purpose of moving care to the patient is to facilitate their lifestyle.
Freethink: Do cancer patients who receive home care have similar outcomes to those in hospitals?
Dr. Handley: There’s some data for patients with cancer—not a ton, but there’s some, and some of the data comes from overseas. Switzerland and France are where the two big studies have been done. They looked at giving patients the chemotherapy that they would receive in the hospital, or sometimes in the clinic, and they have quantified the cost savings and the patient experience for delivering that in the home setting. They found that (a) it’s feasible, (b) the patients like it, (c) it’s safe, and (d) and it cost about 50 percent less.
The total cost of care is dramatically lower, in part because the overhead associated with hospitals is just so high.
Freethink: That sounds fantastic—why hasn’t it taken off here in the US?
Dr. Handley: The biggest reason is the reimbursement part of it is more complicated in the US. But that’s changing, and in a couple years I think that’ll be different.
A lot of places where hospital-at-home programs are well established, have either a single-payer systems or mechanisms by which the cost of care is capped, which means basically there’s a lump sum of money that is available for treating a patient. So, there is an incentive to reduce the total cost of that care while providing very high quality care.
In the US, we are still primarily a fee for service system, which means physicians and health systems get reimbursed based on the services that are delivered to patients. So, there’s essentially an incentive to deliver more care and to deliver care that can be billed at a higher level.
Freethink: How is that changing here in the US?
Dr. Handley: There is this movement afoot of value-based care, which is basically delivering care that is at a higher quality and lower cost. Health plans and big payers like Medicare and Medicaid are really, really interested in this. This means we could be moving to a decentralization of care—basically an un-scaling of care, where these big health systems end up moving more and more things out of the hallowed halls of their flagship hospital.
Freethink: Are you getting any pushback from doctors who may think this is too much of a burden on their schedules?
Dr. Handley: I think there will be. In the early phases of this program, there will probably be a few dedicated providers before it’s something that everyone is doing.
Freethink: You mentioned that at-home care has been the predominant form of care and it’s only been in the last few decades that we shifted to hospital settings. Why the shift?
Dr. Handley: I think a lot of it is economies of scale—the idea is that it’s much more efficient to have a time dedicated for inpatient providers. It streamlines the provider’s workflow, because they don’t have to go back and forth between hospital and clinic. And, more broadly, there’s been a centralization of care because health care became much more complicated pretty quickly.
But now, as technology continues to advance — and we’re seeing this in a lot of other industries too – the need for centralization is not as prominent. The whole concept of brick and mortar is in many industries starting to go away. We are in the very early stages of seeing that in healthcare. I don’t think it’s going to totally ever go away in healthcare, but we’re in a position now where it’s not critical.
Freethink: It seems like technology is actually allowing us to go back to the old ways of doing things.
Dr. Handley: Exactly. Broadly speaking, we’re going to be seeing that more and more in healthcare. There’s a company called Landmark Health that does physician home visits for patients who have very complex care—patients who have seven or more comorbid conditions. It’s an interesting model where they partner with health plans, and say, “Okay, we can reduce the total cost of care for these patients by providing that coordinated care in the home setting.” They’ve done that, and they have been pretty successful in growing that model.
Freethink: Where else in the US is at-home care being done successfully?
Dr. Handley: Johns Hopkins is one. Also Mount Sinai has a program that is pretty well established. They received a big grant from Medicare a few years ago to test their model, and their model is called the Mobile Acute Care Team. Brigham Health in Boston just piloted in a model. They are newer to the game, but they just did a clinical trial, which showed that total cost was significantly lower, patients were more physically active, and patients liked it. It’s a very small study, but they’re getting in it.
There’s some health systems that are well positioned to do this now, and those are really the systems that are fully integrated. That is, they are both the providers and the health plan. So places like Kaiser Permanente and Geisinger that are already like those European entities, in that they are responsible for the total cost of care, so they’re incentivized to reduce costs.
Freethink: What are the biggest concerns you have heard about this at-home approach?
Dr. Handley: One of the concerns about a patient-centric model is that it has the potential to change the relationship between the patient and their care team. Models like this view patients as patients, but also as consumers of healthcare. That concept often gets a lot of pushback, because “patients as consumers” seems like it depersonalizes care.
I think actually the opposite is true. I think we have a lot to learn from progressive industries that are very consumer-centric. Models like this have given us the opportunity to really understand what patients want, which is not how things have always gone historically. It’s been a very paternalistic approach, and that is going to change. That’s exciting.
