Only 20 years ago, about 6 million people were enrolled in health maintenance
organizations (HMOs). Today, 20% of the population (over 58 million people)
are enrolled in HMOs, and about 45% (152 million) have health-care plans
that have some of the essential features of an HMO. Descriptions of
the various types of managed-care organizations (MCOs) can be found in
Clearly, there is more to managed care than cutting costs.[2-4] The
essential characteristics (gold standard) of managed care are:
- Accountability for results
- Cost containment
- Measurement of health-care outcomes
- Health promotion and disease prevention programs
- Resource consumption management
- Emphasis on primary care
- Continuous quality improvement
These features provide the foundation that supports "proper"
The MCO at its best would conform to the blueprint set forth above.
An informal telephone inquiry of a cross-section of the MCOs that are clients
of the Medical Care Ombudsman Program of the Medical Care Management Corporation
in Bethesda, Maryland, revealed good intentions and processes to follow
through on those intentions.
For example, the better MCOs are striving to attain the goals set forth
in that blueprint and want to know when they are perceived as failing to
do so and what they can do to improve. These MCOs routinely seek help in
setting up a treatment plan for difficult cases at the earliest stages
of diagnosis. They also quickly refer patients out when the best level
of care is available elsewhere, even when elsewhere is across the country.
The MCOs contacted (1) are concerned that fully informed consent is obtained
from patients, (2) shared the results of outside review of their medical
records, (3) directed patients to centers of excellence and to meaningful
clinical trials, when available, and (4) were open to exploring other therapeutic
options when patients were ineligible for the treatment plan being proposed
for their care.
A similarly informal telephone survey was conducted among cancer patients
who had utilized the Medical Care Ombudsman Program volunteer program to
help solve problems related to issues with their MCO. This survey elicited
the following typical problems:
- Wrong frequency of needed follow-up tests
- Refusal to refer the patient when the needed diagnostic equipment was
not available within the program
- Refusal to provide psychosocial care or refer the patient out for such
- Reluctance to provide care internally for late effects of cancer treatment
and refusal to refer externally to specialists for such care
- Genetic discrimination; ie, when tests disclose a genetic link to disease,
either do not disclose the information or do not effectively manage, counsel,
and provide psychological interventions as needed
- Propose the cheapest intervention and fail to disclose other options
even when they would likely be more effective for the individual patient
than the option disclosed
- Lack oncologists with training in the intervention sought
- Practice skimming; ie, make the MCO "user-unfriendly" to
persons with disabilities and serious illnesses so that the intelligent
shopper with those problems will find the plan unpalatable. Several instances
of this practice were verified.
The Gold Standard
Ideally, the care of cancer involves a partnership among the patient,
family or significant others, and oncology care team.[5,6] Oncologists
view themselves as the patient's ally and advocate. Traditionally, the
oncologist and patient have drawn the road map for the patient's care.
This road map has provided access through oncology specialists to appropriate
screening, diagnostic tests, standard and new treatments, and, increasingly,
participation in well-designed clinical trials.[5,6] Referral for participation
in meaningful clinical trials is considered the standard of care when patients
have exhausted proven treatment options or when those options are inappropriate.[7,8]
Realities and Challenges Under Managed Care
Left to its own devices, managed care may take the development of the
treatment road map largely out of the hands of the patient/oncologist partnership
in favor of a one-size-fits-all system of cancer care. The oncology community
must take a proactive stance to affirm the right to develop cancer care
management systems that retain sufficient flexibility to accommodate individual
patient requirements and foster the seamless integration of care.
To attain this seamless integration in the managed-care era, the oncology
community must change with the times, throw off the impediments of inefficient,
unnecessary care, and become partners with MCOs in the delivery of proper
cancer care. Oncologists must be willing to become the community's conscience
to ensure that MCOs provide proper cancer care. How oncologists meet this
challenge will depend on their level of commitment and the resources that
each participant--medicine, managed care, and consumer--is willing to expend.
Essential Responsibilities of the MCO
An ideal cancer management program within an MCO includes activities
designed to help enrollees avoid cancer; to promote early detection of
cancer; to furnish the best treatment and follow-up (over both the short-term
[for recurrences] and long term [for secondary cancers]) of cancer patients
and survivors; and to monitor for late effects. The MCO's efforts in these
areas should target enrollees in their communities, at home, and in the
workplace. Environmental hazards specific to a particular community should
factor into MCO planning, as should how to provide and handle genetic testing
and its ramifications for the enrollee and family.
The MCO assumes the responsibility for helping the enrollee lead a healthy,
productive life. Managed care can do a much better job of promoting wellness
and prevention and early detection of cancer than can traditional fee-for-service
medicine. These goals can be achieved by offering regular, periodic communications;
providing health education to encourage wellness and prevention (eg, eating
a healthy diet, getting an annual mammogram), including information carried
on the Internet; and offering such preventive interventions as smoking
cessation and exercise programs.
In many plans, especially "gatekeeper" plans, the primary-care
physician is the initial point of contact, although open-access plans (where
a patient can go directly to a specialist) are becoming very popular. In
both types of plans, practice policies should establish what should be
done for a particular patient and when to refer that patient. Quality assurance
and quality improvement programs should ensure that the right practice
policies have been implemented and that these policies are being followed.
This approach should reduce such problems as misdiagnosis of cases, failure
to refer, and so on.
Compared with traditional fee-for-service medicine, MCOs can provide
the alert consumer and worried-well with better access to medical advice
and also can manage demand for care more cost-effectively. The ask-a-nurse
and other demand management programs are examples of approaches that have
proved successful in this regard.
Through health education (to motivate patients to seek care and advice),
and by providing greater access to screening and other preventive interventions,
MCOs should be able to detect and treat patients with cancer at earlier
stages--a strategy long held to improve the chances of survival.
Through the adoption of policies that embody the best medical practices,
MCOs should contribute to improvements in treatment. These policies should
cover who should treat the patient, and where, how, and when that treatment
should be provided.
Managed-care organizations can coordinate care, ensure proper follow-up,
and help patients enhance their quality of life. The fact that MCOs are
responsible for patients' continued care should eliminate the problem cancer
survivors have had in finding affordable health insurance. Managed-care
organizations should also educate employers about how to deal with cancer
survivors, eg, if that is necessary to promote the patient's rehabilitation.
How the Oncology Community Can Enhance the MCO Model
The activities described above constitute a well-rounded program to
address cancer issues within an MCO. The oncology community's opportunities
to shape the way an MCO fulfills its mandate vary from community to community.
What cannot vary is the commitment of oncologists to do whatever is needed
to achieve ideal cancer care in their community. Furthermore, they must
take concrete steps to communicate to the MCOs their readiness and willingness
to help in these endeavors.
There are many ways in which oncologists can play an active role in
managed care. For example, they can become external consultants for local
MCOs and their primary-care physicians or in-panel oncologists via a hands-on
or teleconsultation "mentor" program. In these roles, oncologists
can provide continuing education, participate in discussions of individual
patients' concerns, review and update standard-of-care protocols, and ease
patients' referral to specialized care when it is preferable (or, from
the MCO's perspective, unavoidable) or their entry into meaningful clinical
trials. In this way, the cancer center/group practice and MCOs would form
a user-friendly integrated delivery system.
Managed-care organizations have every incentive to use specialists if
it can be shown that the care provided by specialists is the most cost-effective.
Managed-care companies also have incentives to ensure that specialists
follow established practice policies and practice efficiently. Given the
same demonstrated patient outcomes, plans will naturally contract with
providers who can offer lower cost and greater patient satisfaction (eg,
more convenient locations and office hours, friendlier staff). Responsibility
for follow-up, again, naturally depends on the cost-effectiveness of primary-care
physicians vs specialists.
Disease-specific groups that are heavily involved in prevention and
education, such as the American Cancer Society, could consider offering
stepwise educational programs to prepare MCO members of all ages to be
informed consumers of medical care--particularly cancer care--and to avoid
health and cancer risks.
Cancer survivors, particularly survivors of childhood cancer, require
special follow-up. The oncology community must make MCOs aware of the need
to provide surveillance of cancer survivors as part of their follow-up
obligations to their enrollees.[9,10] The oncology community should provide
ongoing education and support to the MCO to devise and implement protocols
for the follow-up of long-term survivors of cancer.
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