Where Are We Going and What Questions Do We Need to Ask?

September 1, 1995

This column is the first in a series of articles in Oncology News International that will focus on the impact of managed care on oncology practice. The series will discuss aspects of managed care that need to be considered by oncologists, either in communities or in academic centers, to remain state-of-the-art into the 21st century.

This column is the first in a series of articles in Oncology NewsInternational that will focus on the impact of managed care ononcology practice. The series will discuss aspects of managedcare that need to be considered by oncologists, either in communitiesor in academic centers, to remain state-of-the-art into the 21stcentury.

Why is this type of column worthwhile? Oncology has been one ofthe most exciting specialties in medicine over the past yearsbecause of the impact of new technology. This has increased theability of physicians to cure and manage neoplastic disease.

Oncologists have had professionally satisfying opportunities toapply different technological advances (eg, in genetics, pharmacology,infectious disease, and psychology) to a diverse group of patients.In addition, they have had the opportunity to conduct a wide rangeof challenging clinical investigations in a setting in which patientshave been willing to undergo intensive therapies.

However, with the recognition that payers in American society(employers, corporations, individuals, and the federal government)are no longer willing or able to pay "whatever it takes"to get the maximal care necessary to improve the health of everyindividual, limitations have been placed on payments for healthcare. Globally, these are called health-care reform.

Health-care reform involves a new paradigm, including review ofthe decisions of oncologists by others--managers at insurancecompanies and corporations (often nurses), as well as governmentclerks and administrative personnel, and even our own peers.

Society has now formed a consensus that limitations must be placedon medical resources. Individuals, however, still demand thateverything be done, leading to ethical dilemmas in certain situations.

How should today's oncologist prepare for this increasing degreeof limitation of resource utilization as we proceed into the 21stcentury? What issues should an on-cologist be addressing todayso that he or she can, over the next few years, continue to bringhigh quality health care to individuals while also managing resourcesin a cost-effective manner?

This column will bring the best ideas of a wide range of individualsto address these questions. How an individual on-cologist answersthese questions will determine whether he or she is able to treatpatients effectively and, indeed, to "survive" in thesetting of health-care reform.

Health-care reform is taken to mean the changes that are occurringin American medicine, largely as a result of "market forces"rather than legislation by federal or state governments.

Indeed, as health maintenance organizations (HMOs) evolve andhave responsibility for increasing numbers of people ("coveredlives"), the relationship between oncologists (either incommunities or academic centers) and payers for that care willdetermine the rate of evolution of technology in oncology.

Ten Areas of Inquiry

These are the questions that will be answered in these columnsover the next year:

1. How much impact will managed care have in the marketplaceof the future? Will managed care represent 20%, 50%, 80% (or more)of the patients for whom we care?

2. Will the presence of the managed care environment affect decisionmaking by the individual oncologist? Will the oncologist be ableto bring to bear all the technologies that he or she considersnecessary to treat an individual patient?

3. What will be the relationship between the primary care physician,family practitioner, or internist and the medical oncology subspecialist?What will the primary care physician expect from the oncologist,and what will the oncologist expect from the primary care physician?

4. How will this relationship be affected by different methodsof payment for patients with cancer? Will the same kinds of decisionmaking be possible for patients covered by discounted fee-for-serviceplans, fee schedule plans, case rate payment, and capitated plans?

How will the use of drug therapy be affected by managed care?How are pharmacoeconomic analyses performed, and what will bethe impact of these analyses on medical decision making? How willquality of life assessments be used to perform pharmacoeconomicanalyses?

5. What has been the experience of oncology practices in marketswhere large managed care programs predominate? Has the experiencebeen positive, and if not, what were the major problems and howcan they be solved?

What kinds of outcomes are needed to evaluate the success of oncologypractice in a managed care environment? How have academic centersapproached the managed care opportunities so far?

6. How are high cost procedures such as bone marrow transplantsto be covered in a managed care setting? Who will perform theseprocedures, and can we continue to develop further high cost procedures?Will clinical research have a role in medical oncology in thefuture in a managed care setting?

Clinical Pathways

7. What approach is being taken to develop "clinical pathways"in cancer, and how will these be applied in a managed care setting?What experience has there been with establishment of practiceparameters, and can these be used to protect access to care whileproviding responsible limitation of care?

8. What role does organized oncology have in developing managedcare strategies in the future? How can an individual practicedetermine its costs for delivering care so that contracts canbe established that benefit both the managed care organizationand the oncology practice? What kinds of cost analyses can bedeveloped that help in the management of an individual oncologypractice, either in the community or an academic center?

9. What are the potential legal pitfalls when signing a contractwith a managed care organization to provide oncology services?Are these problems common, and does the individual oncologistor group have any leverage in modifying these contracts?

10. Most important, how do we measure quality in oncology, andhow are we going to determine if quality is being delivered ina managed care setting?

Can you answer these questions? If you cannot, or if you're uncertainwhether your answers really are correct, then this column is likelyto be of help to you.

We hope that you will contact Oncology News International aboutthe articles as they appear in this column over the next year,to express your opinions or to ask further questions that canbe addressed in future articles.