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Guidelines Might Solve Both Clinical, Economic Problems

Guidelines Might Solve Both Clinical, Economic Problems

HOLLYWOOD, Florida —The use of clinical practice guidelines such as those developed by the National Comprehensive Cancer Network (NCCN) is emerging as a key strategy for assuring cancer patients access to quality care; for empowering physicians professionally, politically, and financially; and for reducing health care costs. Panelists discussing "Oncology Practice Today" at the NCCN 11th Annual Conference repeatedly pointed to the usefulness of guidelines in quality evaluation, designing insurance coverage, and obtaining adequate reimbursement.

The problem of assuring cancer patients access to high-quality care engaged all the panelists. Although this problem is sometimes presented in the consumer press as being a purely economic matter, patient advocate Mary Lou Smith, JD, MBA, who heads the Research Advocacy Network, Arlington Heights, Illinois, said that is not the case. "Not all patients [even with insurance] have access to quality care, defined as care according to accepted guidelines," she said.

Lee Newcomer, MD, of United HealthCare, Edina, Minnesota, illustrated the problem. "We insure over 100 million lives and spend about $3 billion on cancer care," Dr. Newcomer said. "A study of Herceptin [trastuzumab] claims showed that 12% of patients treated with Herceptin either did not have the genetic test [for HER2] or did not have the gene overexpressed. A potentially dangerous drug, associated with cardiovascular risk, was being given to many patients who were unable to benefit from it."

Blue Cross/Blue Shield's Allan Korn, MD, added another perspective from his group's experience insuring 94 million lives. Dr. Korn said that oncologists need to pay more attention to how they treat patients who are in the terminal stages of cancer. "When physicians fail to realize they are prolonging death rather than prolonging life, that is a failure of the system," Dr. Korn said.

Panel moderator Clifford Goodman, PhD, of The Lewin Group, Fairfax, Virginia, asked about the state of the art in assessing quality of cancer care. Jane C. Weeks, MD, of Dana-Farber Cancer Center, said that oncologists particularly need better ways to measure outpatient outcomes. "For most patients, adverse events come many years after treatment," she said.

Peter B. Bach, MD, of the Centers for Medicare and Medicaid Services (CMS), described the Medicare program's struggles with the quality issue. Dr. Bach said that current Medicare claims data are not sufficiently detailed to measure quality and that CMS is seeking methods for developing better data about disease characteristics and outcomes in individual patients.

"We need to pay for quality, but first we need to understand what it is and how to measure it," Dr. Bach said. He also pointed out that just the action of reporting in a standardized and proactive way has improved quality of care in pilot studies, a result known as the Hawthorne effect.

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