Payers May Ignore Aspects of Care Most Important to Patients

CHICAGO—As the health care system in this country shifts from fee for service to managed care, private and public payers are being forced to make decisions about the oncology services they purchase. As payers struggle to define the scope of their coverage of oncology services, however, they may be ignoring the aspects of care that are most important to patients, speakers said at a conference on purchasing oncology services, sponsored by the American Cancer Society.

“The problem we’re dealing with is one of an alignment of available resources with patients’ needs,” said I. Craig Henderson, MD, of the University of California at San Francisco. “Based on the needs of society, legislatures decide how much to spend on health care versus, say, the military. In the private sector, businesses are deciding whether to spend more on production or to become more competitive by reducing their health care costs.”

The central issue, however, is how purchasers can control spending and still meet patients’ needs, which are “almost unlimited,” Dr. Henderson said.

Of the four methods for controlling heath care expenditures—the use of a gatekeeper, evidence-based decision-making, incentives targeted to physicians, and market forces that play on patients directly—the first three, which are the most common vehicles for payers, “leave out the patient as part of the definition,” he said. As a result, the purchasing decisions made by payers often do not satisfy patients’ fundamental concerns, he said.

Discrepancies in Coverage

In the case of breast cancer, for example, there are many diverse aspects of care that affect the quality of life and survival of patients: The time spent by physicians interacting with patients; involvement of patients in support groups, self-directed activities such as exercise and alternative forms of treatment such as acupuncture; participation in clinical trials; and bone marrow transplantation, Dr. Henderson pointed out.

However, purchasers offer only limited coverage or set low rates of pay for the time physicians spend counseling cancer patients. Payers provide almost no coverage for participation in support groups or alternative treatments, and “coverage of clinical trials has been a hard-fought battle over the last 3 or 4 years and still is far from won.”

On the other hand, he pointed out, bone marrow transplantation, “which is far and away the most expensive of all these things, is being mandated by Congress for people under CHAMPUS even though the evidence of its effectiveness on improving survival and quality of life may be no greater than for these other things.” Dr. Henderson as well as other physicians and consumer representatives at the conference therefore stressed that payers should include patients in their purchasing decisions.

Purchasers at the conference, on the other hand, were not sure how the goal of incorporating members’ input into purchasing decisions could be accomplished. “The concept of the primacy of the patient is an excellent point,” said Dale Orred, corporate benefits manager, United Parcel Service, Atlanta. He noted, however, that “if I went to the UPS folks who are covered by our health plans and asked what types of health care they would most like covered by their plan, many would answer cosmetic surgery.”

Given free latitude, many cancer patients would insist on coverage of costly but futile end-of-life interventions, and many would seek unproven treatments, said Dean H. Gesme, Jr., MD, an oncologist from Cedar Rapids, Iowa, “because we have not educated our patients well enough for them to understand what their real choices are. Patients want information, and we must, as providers and payers, get together to provide it.”