In this column, Dr. Alan Nelson, past president of the American
Medical Association, has provided a set of goals for oncologic
treatment under managed care contracts that can be embraced by
all oncologists--choice, broad scope of practice, and communication.
But the real message to oncologists is: Work together with internal
medicine and primary care physicians to build a system that provides
quality care of which everyone can be proud. Such cooperation
is needed to help convert these treatment goals into workable
contracts with primary care groups, HMOs, and/or insurers.
The patient's choice of an oncologist is often limited by the
lack of a point of service option in many contracts, and by the
payer's desire to limit risk and cost by capitating oncology services
to the lowest priced specialist. Under managed care, the broad
scope of oncology practice is encour-aged if the oncologist is
providing care on a capitated basis, but discouraged for financial
reasons through utilization review committees if the payer is
contracting with the oncologist on a discounted fee-for-service
basis. Communication between the patient's oncologist and primary
care physician is desirable, but capitalization of computerized
medical systems to facilitate such communication is expensive
for an industry already under heavy cost-containment pressure.
The take-home message of Dr. Nelson's perceptive description
of our important goals might be to work collectively in organized
groups or networks to negotiate with the primary care group or
payer to incorporate these concepts. Only if we pay careful attention
to these issues will we be able to preserve the quality that will
characterize successful health-care reform. Indeed, both oncologists
and insurers must remember that we are not negotiating for "covered
lives" but treating real people who are suffering.--Cary
Presant, MD, Series Editor
Although the health-care delivery system may change, fundamental
values of patient care do not, and to maintain those values, generalists
and oncologists must work together in this new era.
The health-care system is being restructured even though no federal
legislation is driving the process. Managed care is transforming
the way cancer care is delivered by interposing a "gatekeeper"
between the patient and the oncologist.
Many managed care plans are disrupting traditional referral patterns,
and some are defining the scope of an internist's practice. Such
plans may allow a sub-specialist to provide only consulting services
or only primary care, but not both--a distinction that is often
Capitated plans may reward physicians for doing less rather than
more. And because of plan restrictions, patients may have legitimate
concerns about whether they will be able to choose their physicians
and have access to new technology.