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 costs.
"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," he said.
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," she said.
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."
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