Eventually, maybe within 2 years, oncology specialists will become
the primary-care physicians for patients diagnosed with cancer,
managing those patients through the extent of their treatment
and follow-up, Kenneth R. Melani, MD, said at the Fifth Annual
Pittsburgh Cancer Conference.
He also believes it makes sense for specializing physicians to
form capitated service networks, where each network takes full
control of patient management within a specific medical category.
Barry C. Lembersky, MD, commented that if that becomes the case,
academic medical centers must get into the network, as many patients
will eventually need their services. "Also, because we are
researchers and educators, I think society will want us there
to try and improve the state of the art," he said.
Dr. Melani, Executive Vice President of Blue Cross of Western
Pennsylvania, and Dr. Lembersky, Assistant Professor of Medicine,
Division of Medical Oncology, University of Pittsburgh Medical
Center, spoke during a panel discussion on health reform.
Kathy J. Selvaggi, MD, Medical Director of the Richard Laube Cancer
Center at Armstrong County Memorial Hospital, Kittanning, Pennsylvania,
agreed with Dr. Lembersky that university centers must get into
the network. She said she often wants to send patients to the
university, but managed care makes it difficult, first because
of the cumbersome requirement that the primary-care physician
request the services, but primarily because insurance won't cover
"As a hematologist/oncologist in rural America, I can tell
you my patients can't afford $1,800 for a CT scan," she said.
"Even if we do get authorization, travel and parking costs,
minimal as they may seem to us, can be a real hardship. Then,
if a patient is admitted, their entire support system is back
in the country."
Edward J. Benz, Jr., MD, Jack D. Myers Professor and Chairman,
University of Pittsburgh Department of Medicine, commented that
a university is not just buildings, walls, and equipment.
"The most important part is human resources, people with
knowledge and expertise who advance the state of clinical care
and generate new knowledge," he said. "We need to think
of the university as a campus without walls, and develop a better
way to provide access to its special resources without forcing
patients to come to it."
Dr. Lembersky, who is also Medical Director of Community Outreach
at Pittsburgh Cancer Institute, agreed that universities, physicians,
and the community need to work better together. "We have
taken initial steps to spread our network throughout all of western
Pennsylvania, and already have 11 participating hospitals,"
Financing Physician Education
Managed care may affect the training and education of students,
fellows, and researchers, Dr. Benz said. "If you separate
teaching from research, you cease to have education, and simply
have occupational training."
He said that the physician/scientist, traditionally financed by
a combination of federal support and the redirection of health-care
profits, is an endangered species, because those profits are now
being redirected into large corporate entities and equity markets.
During the congressional debate on health-care reform, there was
no mention of putting those profits back into the system, he said,
because there is currently no way to prove that training the physician/scientist
is cost effective.
Comparing today's environment to that of the 1940s, when Dr. Jonas
Salk's study of viruses seemed not at all cost effective, Dr.
Benz said: "If Salk hadn't done that, would we be treating
polio patients with a laser-driven iron lung instead of preventing
it with a vaccine? Cost effectiveness of today's basic research
and new treatments may be apparent only 10, 20, 40 years from
now. I think there will be a short-term, very negative effect
of managed care on the training and education of people who can
carry the state of the art forward," he said.
Who Pays for Trials?
The great advances in oncology are primarily attributable to basic
and clinical research, Dr. Lembersky said, but in the absence
of legislation, the free market will be tough on clinical trials.
"Managed care does not wish to spend money on trials that
are innovative or experimental," he said. "However,
trials must be supported to advance knowledge, cure more people,
and provide better quality of care."
Dr. Lembersky was not sure where the money should come from-perhaps
a surcharge on insurance companies as they make profits from the
delivery of quality health care at lower costs, or greater government
support, maybe from taxes on insurance company profits.
"But the money is necessary," he said. "More importantly,
we need access to patients. My nurses and I spend an inordinate
amount of time trying to convince HMOs there is no other reasonable
option for a particular patient, and that we have a reasonable
phase I or II clinical trial. It's a big problem."
Because Armstrong Memorial is a member of the Pittsburgh Cancer
Institute community network, Dr. Selvaggi said that some trials
are "doable" at their facility but, again, coverage
is a problem. "When I present clinical trials to patients,
the overwhelming question is: 'Can I stay at our county hospital
and get good care, and who will pay for it?' We are trying all
angles, but it's getting very difficult for us in the rural setting,"
Dr. Melani said he was certainly in favor of insurance companies
doing more for the community. "For 57 years, Blue Cross has
supported research and education more than any other third-party
payor in the country. Unfortunately, we now have others in the
marketplace that don't believe that's necessary, and we have significant
price competition. It becomes difficult to contribute heavily
and remain competitive."
He commented that the academic world, to some degree, had become
accustomed to endless dollars flowing into research and education.
"Whether those dollars come from third party or government,
they come out of the consumer's pocket."
Consumers can appeal a decision to deny coverage for treatment
considered experimental through the carrier, the employer, or
the legal system, he said, adding that payors are finding it more
difficult to sustain these decisions when confronting a legal
system that, he believes, is sensitive to the individual.
"My problem is the crossover; how do you define treatment
or trials that are actually harmful...?" he said. "The
pendulum seems to be swinging back the other way, to where we
are almost forced to pay for everything and anything."