Q&A with Mark Hornbrook

Cancer costs the U.S. an estimated $200 billion per year, including more than $77 billion for medical care.  Understanding the drivers of these costs and their relationships to health care quality and patient outcomes is a critical focus of the work of Dr. Mark C. Hornbrook.  Mark C. Hornbrook, PhD, is a health economist and Chief Scientist at Kaiser Permanente's Center for Health Research and a recognized expert in research focusing on the determinants of medical care utilization, expenses, economic burden, health outcomes, and comparative effectiveness.  Dr. Hornbrook is a member of the Executive Committee of the Cancer Research Network and co-leads the CRN Health Care Quality and Cost scientific working group (with Drs. Jane Weeks and Debra Ritzwoller).  

Dr. Alyce Adams, Co-Lead, Outreach and Collaborations Core for the CRN, recently sat down with Dr. Hornbrook to discuss the importance of the CRN and how others can leverage these unique resources to answer cutting-edge research questions.

Dr. Adams:  How did you get involved in the Cancer Research Network?

Dr. Hornbrook:  I was actively involved in the creation of the HMO Research Network as an investigator at the Kaiser Permanente Center for Health Research.  When the NCI issued the RFA for the CRN, the HMORN Board decided to respond as a group to demonstrate the CRN’s viability as a foundation for multi-site population-based research.  Dr. Ed Wagner, Director of Group Health Cooperative’s research center was designated as the overall PI for the CRN proposal.  While I had no prior cancer research experience, I wanted to support Ed’s vision that the HMORN could serve as an innovative platform for multi-center cancer research.  I was particularly interested in the development of the CRN from an informatics perspective and the potential a distributed data model held to revolutionize cross-institutional research.  My ultimate goal was to build the capacity of the CRN to conduct research on determinants of utilization, outcomes, and costs for cancer patients.  I knew this work would need high quality, comprehensive utilization and survival data, in other words, the Virtual Data Warehouse.

My work on the common data infrastructure and the Virtual Data Warehouse, the CRN, along with the AHRQ-funded Centers for Education and Research on Therapeutics (CERTs), generated the proof of concept that standardized distributed data warehouses greatly facilitate multi-site research.

Dr. Adams:  In addition to your many active research studies, you are also the Principal Investigator for Medical Care Burden of Cancer: System and Data Issues study, a National Cancer Institute funded study to develop a multi-site, multi-payer database to support analyses on the determinants of cancer costs in fee-for-service and HMO settings.  What motivated you to conduct the BURDEN study and what have been the key findings to date?

Dr. Hornbrook:  The BURDEN study started as a R01 that was independent of the CRN.  I wanted to examine the determinants of the incremental medical care costs of cancer (above the background level of medical care costs to meet all other care needs).  The study was later brought in under the CRN so that we could spread the use of the BURDEN methods to other research settings and facilitate outside collaborations.  When we started the BURDEN study (2007), the only available datasets on expenditures for cancer care were primarily the SEER Medicare data files, which excluded managed care populations.  The reason for this exclusion was that while health plans provide claims data for the creation of a CMS risk adjustment model to pay Medicare Advantage plans, data on charges from HMOs were omitted.  As a result, there was no way to get cost data on managed care populations.  BURDEN is the 1^st resource to provide managed care resource costs for adults with cancer.  This facilitates analyses of patterns of care, costs, and cost comparisons.

Dr. Adams:  How do you envision others leveraging the power of the BURDEN dataset?

Dr. Hornbrook:  We encourage external investigators to consider collaborating with our research team on using the BURDEN database to facilitate their research project.  We have collaborated with investigators within and outside of the CRN to leverage the power of the BURDEN dataset through small pilot projects and projects led by CRN Scholars.  The availability of common master agreements as part of the CRN collaborative process facilitates this kind of data sharing.  It’s important to be sure that Scholars and others do not face insurmountable data access issues or challenges and can generate findings quickly for proposals and publications.

Dr. Adams:  Are there critical unanswered questions that the BURDEN dataset is uniquely positioned to answer?

Dr. Hornbrook:  The BURDEN/SEER-Medicare datasets can support investigations into the sources of relative cost savings of HMOs versus FFS in cancer care; investigations of variations in costs among HMO cancer patients; the reasons for high costs of end-of-life care; investigations of the patterns of regression to the mean (the tendency for extreme costs to return to near average levels upon repeated measurement) when comparing FFS to HMO costs; examination of variations in treatment costs across types of cancer; analyses of the effects of comorbidities following a new cancer diagnosis; the quality of life consequences of cancer treatments for cancer survivors; and what constitutes affordable cancer care.

Dr. Adams:  If someone is interested in learning more about the BURDEN dataset, what is the best way for them to find out more?

Dr. Hornbrook:  They should contact me or my co-leads in the Health Care Quality & Cost (HCQC) Scientific Working Group Drs. Debra Ritzwoller, PhD, Institute for Health Research, Kaiser Permanente Colorado, or Jane C. Weeks, MD, MPH, Dana Farber Cancer Institute via Joanna E. Bulkley, PhD, Joanna.E.Bulkley@kpchr.org.

An Additional Note about Dr. Hornbrook:

Dr. Hornbrook’s work has produced over 190 peer-reviewed journal articles and book chapters. He served as a Commissioner on the Physician Payment Review Commission (PPRC), Congress of the United States, from 1986 through 1990. During his tenure, the PPRC developed the Medicare Fee Schedule and Volume Performance System reforms of the Medicare Part B payment system. Dr. Hornbrook also served as a member of the National Committee on Vital and Health Statistics, from 2008-2012, where the key policy issues being addressed related to guidelines and incentives for installing electronic medical record systems.