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 unnatural.
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.