In Los Angeles, the future seems to arrive a little sooner than
in the rest of the country. The defense-based economy has crashed
and burned, shifting hundreds of thousands of employees into managed
care plans, mostly HMOs.
Nervously clutching our ASCO abstracts in our axillae, medical
oncologists here are knee deep in the results. By the painful
but simple mechanism of full risk capitation contracts, the managed
care industry has reversed two decades of medical oncology practice
history--they think for the better, but we're not so sure. How
did this come about?
Arguably, medical oncology did not exist until the early 1970s
(the first Boards were in 1973) when the combination chemotherapy
theories of Cooper, DeVita, and, later, Einhorn required sophisticated
management of drug protocols and their side effects. Prior to
that time, internists and surgeons were comfortable handling single
agents, and oncology was really a surgical subspecialty.
As it grew in the 1970s and 1980s (the "money is no object"
era in medicine), medical oncology evolved a practice paradigm
of benevolent excess. We used vast permutations of combination
chemotherapy, both empirically and systematically, in hopes of
eradicating, or at least palliating, the sufferings of common
The limited success of most of these programs has not, in general,
caused a reassessment of purpose but, contrarily, has accelerated
ultra-high-dose therapies, requiring the development of disturbingly
expensive modalities and drugs to counter the ever-worsening symptoms
of vomiting, myelosuppression, and infection.
As long as fee-for-service held out on the private practice side,
and government research grants on the academic side, all was well.
However, those who viewed the situation from both a cost and an
outcome perspective questioned whether the confusing variability
in management of specific disease sites, and the lack of persuasive
evidence that one treatment was really better than another, meant
a bit of self-indulgent chaos.
Industry cannot and will not pay any longer, so it invented "managed
care." While traditional medical oncology was based on a
physician-patient compact for as much treatment as wanted by both,
for as long as either could tolerate it, managed care now means
as little treatment as possible, for as small a price as possible.