In Los Angeles, the future seems to arrive a little sooner than in the rest of the country. The defense-based economy has crashed and burned, shifting hundreds of thousands of employees into managed care plans, mostly HMOs.
Nervously clutching our ASCO abstracts in our axillae, medical oncologists here are knee deep in the results. By the painful but simple mechanism of full risk capitation contracts, the managed care industry has reversed two decades of medical oncology practice history--they think for the better, but we're not so sure. How did this come about?
Arguably, medical oncology did not exist until the early 1970s (the first Boards were in 1973) when the combination chemotherapy theories of Cooper, DeVita, and, later, Einhorn required sophisticated management of drug protocols and their side effects. Prior to that time, internists and surgeons were comfortable handling single agents, and oncology was really a surgical subspecialty.
As it grew in the 1970s and 1980s (the "money is no object" era in medicine), medical oncology evolved a practice paradigm of benevolent excess. We used vast permutations of combination chemotherapy, both empirically and systematically, in hopes of eradicating, or at least palliating, the sufferings of common cancers.
The limited success of most of these programs has not, in general, caused a reassessment of purpose but, contrarily, has accelerated ultra-high-dose therapies, requiring the development of disturbingly expensive modalities and drugs to counter the ever-worsening symptoms of vomiting, myelosuppression, and infection.
As long as fee-for-service held out on the private practice side, and government research grants on the academic side, all was well. However, those who viewed the situation from both a cost and an outcome perspective questioned whether the confusing variability in management of specific disease sites, and the lack of persuasive evidence that one treatment was really better than another, meant a bit of self-indulgent chaos.
Industry cannot and will not pay any longer, so it invented "managed care." While traditional medical oncology was based on a physician-patient compact for as much treatment as wanted by both, for as long as either could tolerate it, managed care now means as little treatment as possible, for as small a price as possible.