Eventually, maybe within 2 years, oncology specialists will become the primary-care physicians for patients diagnosed with
Eventually, maybe within 2 years, oncology specialists will becomethe primary-care physicians for patients diagnosed with cancer,managing those patients through the extent of their treatmentand follow-up, Kenneth R. Melani, MD, said at the Fifth AnnualPittsburgh Cancer Conference.
He also believes it makes sense for specializing physicians toform capitated service networks, where each network takes fullcontrol of patient management within a specific medical category.
Barry C. Lembersky, MD, commented that if that becomes the case,academic medical centers must get into the network, as many patientswill eventually need their services. "Also, because we areresearchers and educators, I think society will want us thereto try and improve the state of the art," he said.
Dr. Melani, Executive Vice President of Blue Cross of WesternPennsylvania, and Dr. Lembersky, Assistant Professor of Medicine,Division of Medical Oncology, University of Pittsburgh MedicalCenter, spoke during a panel discussion on health reform.
Kathy J. Selvaggi, MD, Medical Director of the Richard Laube CancerCenter at Armstrong County Memorial Hospital, Kittanning, Pennsylvania,agreed with Dr. Lembersky that university centers must get intothe network. She said she often wants to send patients to theuniversity, but managed care makes it difficult, first becauseof the cumbersome requirement that the primary-care physicianrequest the services, but primarily because insurance won't covercosts.
"As a hematologist/oncologist in rural America, I can tellyou my patients can't afford $1,800 for a CT scan," she said."Even if we do get authorization, travel and parking costs,minimal as they may seem to us, can be a real hardship. Then,if a patient is admitted, their entire support system is backin the country."
Edward J. Benz, Jr., MD, Jack D. Myers Professor and Chairman,University of Pittsburgh Department of Medicine, commented thata university is not just buildings, walls, and equipment.
"The most important part is human resources, people withknowledge and expertise who advance the state of clinical careand generate new knowledge," he said. "We need to thinkof the university as a campus without walls, and develop a betterway to provide access to its special resources without forcingpatients to come to it."
Dr. Lembersky, who is also Medical Director of Community Outreachat Pittsburgh Cancer Institute, agreed that universities, physicians,and the community need to work better together. "We havetaken initial steps to spread our network throughout all of westernPennsylvania, and already have 11 participating hospitals,"he said.
Financing Physician Education
Managed care may affect the training and education of students,fellows, and researchers, Dr. Benz said. "If you separateteaching from research, you cease to have education, and simplyhave occupational training."
He said that the physician/scientist, traditionally financed bya combination of federal support and the redirection of health-careprofits, is an endangered species, because those profits are nowbeing redirected into large corporate entities and equity markets.During the congressional debate on health-care reform, there wasno mention of putting those profits back into the system, he said,because there is currently no way to prove that training the physician/scientistis cost effective.
Comparing today's environment to that of the 1940s, when Dr. JonasSalk's study of viruses seemed not at all cost effective, Dr.Benz said: "If Salk hadn't done that, would we be treatingpolio patients with a laser-driven iron lung instead of preventingit with a vaccine? Cost effectiveness of today's basic researchand new treatments may be apparent only 10, 20, 40 years fromnow. I think there will be a short-term, very negative effectof managed care on the training and education of people who cancarry the state of the art forward," he said.
Who Pays for Trials?
The great advances in oncology are primarily attributable to basicand clinical research, Dr. Lembersky said, but in the absenceof legislation, the free market will be tough on clinical trials.
"Managed care does not wish to spend money on trials thatare innovative or experimental," he said. "However,trials must be supported to advance knowledge, cure more people,and provide better quality of care."
Dr. Lembersky was not sure where the money should come from-perhapsa surcharge on insurance companies as they make profits from thedelivery of quality health care at lower costs, or greater governmentsupport, maybe from taxes on insurance company profits.
"But the money is necessary," he said. "More importantly,we need access to patients. My nurses and I spend an inordinateamount of time trying to convince HMOs there is no other reasonableoption for a particular patient, and that we have a reasonablephase I or II clinical trial. It's a big problem."
Because Armstrong Memorial is a member of the Pittsburgh CancerInstitute community network, Dr. Selvaggi said that some trialsare "doable" at their facility but, again, coverageis a problem. "When I present clinical trials to patients,the overwhelming question is: 'Can I stay at our county hospitaland get good care, and who will pay for it?' We are trying allangles, but it's getting very difficult for us in the rural setting,"she said.
Dr. Melani said he was certainly in favor of insurance companiesdoing more for the community. "For 57 years, Blue Cross hassupported research and education more than any other third-partypayor in the country. Unfortunately, we now have others in themarketplace that don't believe that's necessary, and we have significantprice competition. It becomes difficult to contribute heavilyand remain competitive."
He commented that the academic world, to some degree, had becomeaccustomed to endless dollars flowing into research and education."Whether those dollars come from third party or government,they come out of the consumer's pocket."
Consumers can appeal a decision to deny coverage for treatmentconsidered experimental through the carrier, the employer, orthe legal system, he said, adding that payors are finding it moredifficult to sustain these decisions when confronting a legalsystem that, he believes, is sensitive to the individual.
"My problem is the crossover; how do you define treatmentor trials that are actually harmful...?" he said. "Thependulum seems to be swinging back the other way, to where weare almost forced to pay for everything and anything."