Today, the US health-care system is being driven by a desire to
contain escalating health-care expenditures. Oncology has not
been spared, and the cancer burden on this country is great in
terms of monetary costs as well as human morbidity and mortality.
As managed care health plans turn to clinical financial pathways
and capitation to save money in oncology services, they will ultimately
have to demonstrate the quality of the services they provide if
they expect to remain viable in a competitive marketplace.
Cost Containment Threats
While managed care plans and other efforts at cost containment
do not necessarily result in poor quality of care, policies directed
only at reducing costs are likely to have such an effect. The
quality of oncology care is particularly vulnerable to threats
from cost containment due to a number of unique aspects of cancer
care (see Table 1).
Many clinicians and patients have already witnessed the adverse
effects of haphazard cost cutting, including closed drug formularies,
restrictions on off-label drug uses, denial of coverage for patient
care costs incurred during clinical trials, and overly restrictive
policies governing patient access to oncology specialists, psy-chosocial
services, and specialized facilities like NCI-designated cancer
It is not hard to imagine further restrictions and a greater shift
of the responsibility for patient care to patients and their family
members if policies to guard and improve the quality of oncol-ogy
care are not implemented.
The Cancer Process
While cancer consists of many different diseases, each requiring
specialized care, a general cancer process can be defined. We
divide this process into the following broad phases of care: acute
care, subacute care, and long-term care.
This overall process contributes to the unique aspects of cancer
care that make it so costly. Although this process will unfortunately
not be completed by all patients, it emphasizes the need for coordinated
medical care, both physical and mental, throughout each period.
- Acute care includes detection, diagnosis, and treatment.
The detection and diagnosis phase sets the foundation for the
relationship between the patient and oncologist as well as the
subsequent treatment regimen.