Are we failing to be as efficient as we could be in delivering care to cancer patients, particularly in follow-up after treatment?
Oncology is a team sport. I enjoy the expertise of not only fellow medical oncologists but also the radiation oncologists, surgeons, genetic counselors, oncology nurses, and radiologists who comprise the bulk of the treating posse for most cancer patients. But sometimes I think we fail to be as efficient as we could be in delivering care, particularly in follow-up after treatment.
A recent study showed that cancer patients with Medicare and no supplemental coverage suffer high financial stress due to copays. They paid an average of $8,115 in the first year after a cancer diagnosis. Even patients with Medigap coverage paid an average of $5,670. Much of this is driven by hospitalization, but we all know the majority of cancer care is delivered in the outpatient setting, putting the doctors in the position of having at least some control of costs.
The expense of drugs and imaging is well known and has been addressed multiple times; but have you ever thought about the cost of a simple office visit? For many patients there is a copay of $25–$50 upfront as they walk in the door for the visit. These costs can mount up quickly and strain even those with reasonable savings, pensions, or salaries.
I have a rhythm with many of the doctors I have worked with over the years. For example, a breast cancer patient sees the surgeon, medical oncologist, and radiation oncologist as part of the initial care team. The radiation oncologist sees the patient during radiation and once for follow-up, possibly more often if there are complications to monitor. Then I, as the medical oncologist, would be primarily responsible for follow-up. Typically, the surgeon and I would leap frog our follow-up visits so the patient saw one of us every 3 months, then 6 months and so on, as per guidelines. Of course, the patient can call and be seen at any time if there is a problem. Inexplicably, some doctors have the patient come back repeatedly, some even on the same day that I am seeing the patient. How many doctors need to see the patient for the same thing at the same time? And 4 years after completing breast radiation, does the radiation oncologist still need to see that patient at all?
Some patients become upset and question this because it is expensive and inconvenient (remember, many patients have to take time off from work or have a family member take time off to bring them), and they do not feel there is value in so many visits. As a rule, “value” is not a quality we talk about in regard to healthcare.
Even more frustrating, some of these doctors order inappropriate imaging for patients. How do you explain that to the patient when you have already spelled out the follow-up plan and the CT scan is not indicated? I don’t want to make the patient feel uncomfortable or lose confidence in their team, but sometimes I want to throttle the other team member! You can see where bundling payments would force better utilization in some cases. But that is a whole different discussion that I am not addressing here, so hold your fire!
When my breast cancer patients reach 10 years after diagnosis and are disease-free, I tell them they need to continue yearly mammography but that they are no longer required to see me. I explain that I don’t want them to feel like I am just running them through unnecessary visits. Many are happy to be seen as needed, but some just want to keep coming back and I am thrilled to see them; at least I give them a choice.
I recently saw an orthopedic surgeon about an issue. She was excellent, addressed the issue, and explained exactly what she could and could not do and the possible outcomes. I chose a conservative treatment, and it has worked well. I know the problem cannot be fixed without surgery, but she said that I can wait as long as I want. I did not make a follow-up appointment because there is nothing to do at this point. I filled out a survey after my visit and stated that I was very pleased with the office and the physician. However, they keep calling me to make another appointment. Why? So I can tell her the fix she prescribed is great and I will let her know when it no longer works? Why would I waste her time and mine? I am fairly certain that the healthcare system that owns the practice has a protocol and quota for follow-ups. I received excellent value for my initial visit, but I don’t see the value in a “how ya’ doin?” office visit.
For patients who read this and have the time and resources to go to as many visits as they want, feel free, but physicians need to consider value for patients and what is asked of them in time and money.