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© 2000 American Society for Clinical Oncology
Managed Care and Oncology: The Quality DebatePresident, American Society of Clinical Oncology THE LIVELY DISCOURSE in Congress during the past several months over the Patients’ Bill of Rights has rekindled public interest in the paradox of managed care. For the young and healthy enrollee, managed care’s emphasis on prevention and wellness seems to work. For the elderly and those with serious and life-threatening diseases, such as cancer, however, managed care can be a problem. Escalating public concern over whether there will be access to necessary care—when it’s needed—is reflected in numerous documentaries and news stories, all with themes similar to the recent Newsweek cover story, "HMO Hell." In addition to issues of simple access, patients worry that cost-cutting strategies by managed care plans have eroded quality of care. Fears about access and quality of care are particularly sharp for patients facing a cancer diagnosis. With rising expectations of cures for life-threatening diseases through often-costly modern technology and drugs, the debate grows hotter and more complex. Health plans, many struggling to survive, are seeking ways to cut costs. At the same time, patients want access to cutting edge technology that, although expensive, has never been more promising. These competing interests in an increasingly complex health care system have demanded the attention of national policymakers and called on greater collaboration and communication among health plans, providers, and patients. In a recent speech before Washington, DC, health reporters, Paul Ellwood, MD, a principle architect of today’s managed care, added his voice to the many raised in concern about today’s United States health care system: "The managed care–based health system is failing. Medical inflation is back. Consumer distrust, provider hostility, costly new technologies, and political opportunism will no longer allow costs and quality to be controlled by most existing managed care arrangements." While Ellwood does not believe we are worse off because of managed care, he does suggest that the managed care model originally envisioned by himself and other proponents of a health maintenance strategy in the early 1970s has not lived up to expectations. Managed care did curb inflation over the past three decades, but it has not addressed issues of quality and over- or underutilization. Today’s health system, says Ellwood, is off target. The question is whether current managed care systems can satisfy the requirements of people with cancer and other acute or chronic illnesses. The American Society of Clinical Oncology (ASCO) has not taken positions for or against managed care. Instead, our efforts in Congress and working with industry have been focused on assuring that basic requirements of quality cancer care are met by all health plans. Two critical areas of concentration have been timely access to specialty care and access to high-quality clinical trials. Appropriate care of people with cancer involves early and consistent access to qualified cancer specialists. This is the primary battleground of the conflict over managed care for cancer patients. If cancer specialists can determine the course of treatment for their patients, other critical patient concerns can be resolved, such as choice of therapy and access to clinical trials. The cancer community has long recognized the critical role of access to clinical trials as a component of quality cancer care. The Patients’ Bill of Rights debate confirmed the importance of clinical trial participation to quality care in a managed care setting. Without input from a specialist, cancer patients who could be eligible for participation in a trial might never get the opportunity. If their health plans do not offer clinical trials, patients should have the option to seek appropriate treatment outside the plan. Who makes that decision? In managed care plans, it is usually the primary care physician. A recent study published in the Journal of the American Medical Association highlights the concerns of patients who value coordination of care but fear financial or other incentives undermine their access to necessary specialists or treatment. The concept of a family physician advancing the interests of his or her patients and coordinating needed services was the ideal envisioned by advocates of managed care. Gradually, as managed care penetration has grown in the United States, the family physician advocate is increasingly seen as a gatekeeper. For people with cancer enrolled in managed care, this gatekeeper function is central. An enrollee who presents with a potential cancer diagnosis needs prompt and continuous access to a qualified cancer specialist. Although patients tend to rate their own providers highly, doctors pressed to be cost-efficient health plan participants have less time to invest in patient care, and the traditional trust between doctor and patient is wearing thin. Patients are beginning to fear that the family doctor could represent a delay to life-saving treatment. The stakes may be high for patients enrolled in managed care systems. At least for patients who are elderly or poor, there is evidence that health outcomes are worse under managed care as compared with fee-for-service care. In a large, multisite, observational study, chronically ill elderly patients were twice as likely to decline in health in a managed care setting than in a fee-for-service setting.1 Managed care plans rely on fewer subspecialists than do fee-for-service plans. This limited access to specialized care may be one reason for the decline in health care status among the chronically ill elderly. Is the backlash against managed care turning into a revolution? Aside from the relief represented by the Patients’ Bill of Rights, other forces in the public policy arena may reform managed care practices. A series of lawsuits resulting in high-profile awards against managed care entities may persuade them to take a more reasonable stance on access issues. Judicial decisions in federal courts across the country have permitted suits based on negligent denial of access to necessary treatment.2 These cases include a variety of chronic conditions, including cancer. Although litigation may influence some degree of reform, the change may be too slow and uneven to satisfy patient demands and ensure consistently good results across the board. Who can best change the system? Managed care companies can. They could voluntarily ensure that specialists are involved in medical decision making for cancer patients from the diagnosis forward. The specialist should be part of every phase of treatment and follow-up. Moreover, cessation of active treatment does not end the need for a cancer disease manager. Even beyond the 5-year disease-free status, cancer patients continue to suffer long-term and late effects of therapy and risk of recurrence. The specialist remains an important element of quality cancer care long after conclusion of active treatment. While there is a need for coordination of care by cancer specialists, this does not usurp the role of the primary care physician. Oncologists would fully support reform of managed care that involved heightened coordination of cancer care with appropriate division of responsibility between primary care physicians and specialists. They regard abandonment of a restrictive "gatekeeper" concept in favor of "coordinated care" as the first step toward reconciliation of managed care with quality cancer care for patients. In fact, renewed support for the relationship between patients and their physicians is the core of Ellwood’s vision for a better health care system. The failure of managed care theory can in large part be attributed to the fact that it did not realize the importance of this relationship. Patients judge quality and make health care choices through the advice of a trusted physician, not on mortality data and cost efficiency of competing health plans. Senator Dianne Feinstein (D-CA) calls it having a "quarterback physician." Some health plans have embraced the shift from gatekeeper to quarterback; United Healthcare made the front page of a recent Washington Post with their initiative to put medical decision making back in the hands of treating physicians. The recent creation by the National Cancer Institute of a research network among 10 major nonprofit managed care organizations is welcome. Tasked to pursue cancer prevention and control research, their efforts may lead to more extensive collaboration in the future.3 Responding to public concerns and issues of quality, a number of health plans have developed centers of excellence and in some cases have carved out complex illnesses, such as cancer, for special arrangements. Advocates for cancer patients should not rest until every managed care plan in the country properly coordinates specialty care for individuals with cancer and guarantees access to appropriate care, including participation in clinical trials. Only then will managed care realize its promise of better health through coordination of comprehensive patient services. What can we do? If managed care companies have a duty to assure the system allows delivery of high-quality care, it is the duty of physicians to assure it happens. In April 1999, the Institute of Medicine’s National Cancer Policy Board released a report raising serious concerns about variations in cancer care across the United States.4 The report acknowledges that while there is evidence that many cancer patients do not receive care known to be effective for their disease, there is insufficient information to know the extent or causes of this problem. As the largest professional medical society of physicians who treat cancer, ASCO is in a unique position to assume leadership in addressing these issues. This year, ASCO will undertake a groundbreaking study to address issues raised by the Institute of Medicine. A collaborative effort involving ASCO, the American College of Surgeons, the Oncology Nursing Society, the American Society of Therapeutic Radiology and Oncology, the Society of Surgical Oncology, Harvard University, and the RAND Corporation, this project will develop a methodology for studying—and thereby improving—cancer care across the United States. We will examine all elements of the health care system, including health plan structure, and their impact on quality. With this first step, ASCO members can shine a light on future debate over cancer treatments for Americans in the 21st century. It is a step worth taking. REFERENCES 1. Ware JE Jr, Bayliss MS, Rogers WH, et al: Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. JAMA 276:1039-1047, 1996 2. Pear R: Series of rulings eases constraints on suing HMOs. New York Times, August 15, 1999, p 1
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Moulton G: HMO research network to focus on cancer prevention and control. Cancer Inst 91:1363, 1999 4. Hewitt M, Simone JV (eds): Ensuring Quality Cancer Care. Washington, DC: National Cancer Policy Board, Institute of Medicine and Commission on Life Sciences, National Research Council, 1999
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Copyright © 2000 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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