In the past few years, this country has seen a major change in the financing of health care. According to a recent survey by Foster Higgins, an international employee-benefits consulting agency, at the end of 1994, 63% of all privately insured Americans were enrolled in a managed care plan.
Managed care plans are usually described as those that provide health-care services through health maintenance organizations (HMO), preferred provider networks (PPN), or point-of-service (POS) plans.
The Marion Merrell Dow Managed Care Digest states that as of June, 1994, pure HMO penetration had risen to 20.3% of the total population of the United States, representing a total HMO enrollment of 52.4 million members.
Clearly, the halcyon days of fee-for-service medicine are gone forever. Most of these changes have been driven by employers' demands for cost reduction by health-care providers. Within oncology, the indiscriminate use of laboratory tests, superfluous diagnostic processes, and expensive chemotherapeutic regimens with no documented benefits has resulted in increasing payer scrutiny of physician practices.
This cost-reducing effort has been spearheaded by managed care organizations that encourage physicians to provide only services deemed appropriate, ie, those providing a benefit that outweighs any harm.
This article describes our approach to meeting some of the economic challenges encountered in this new health-care environment. It is our belief that every therapeutic decision that an oncologist makes has an associated economic impact on our health-care system, since resources used for inappropriate therapies may not be available for appropriate ones.
One of the most important tools to aid physician decision habits, and essential to justify the treatment decision, is the use of formal guidelines in high-cost therapies.