Plans Must Show Quality of Care to Remain Competitive

Today, the US health-care system is being driven by a desire tocontain escalating health-care expenditures. Oncology has notbeen spared, and the cancer burden on this country is great interms of monetary costs as well as human morbidity and mortality.

As managed care health plans turn to clinical financial pathwaysand capitation to save money in oncology services, they will ultimatelyhave to demonstrate the quality of the services they provide ifthey expect to remain viable in a competitive marketplace.

Cost Containment Threats

While managed care plans and other efforts at cost containmentdo not necessarily result in poor quality of care, policies directedonly at reducing costs are likely to have such an effect. Thequality of oncology care is particularly vulnerable to threatsfrom cost containment due to a number of unique aspects of cancercare (see Table 1).

Many clinicians and patients have already witnessed the adverseeffects of haphazard cost cutting, including closed drug formularies,restrictions on off-label drug uses, denial of coverage for patientcare costs incurred during clinical trials, and overly restrictivepolicies governing patient access to oncology specialists, psy-chosocialservices, and specialized facilities like NCI-designated cancercenters.

It is not hard to imagine further restrictions and a greater shiftof the responsibility for patient care to patients and their familymembers if policies to guard and improve the quality of oncol-ogycare are not implemented.

The Cancer Process

While cancer consists of many different diseases, each requiringspecialized care, a general cancer process can be defined. Wedivide this process into the following broad phases of care: acutecare, subacute care, and long-term care.

This overall process contributes to the unique aspects of cancercare that make it so costly. Although this process will unfortunatelynot be completed by all patients, it emphasizes the need for coordinatedmedical care, both physical and mental, throughout each period.

• Acute care includes detection, diagnosis, and treatment.The detection and diagnosis phase sets the foundation for therelationship between the patient and oncologist as well as thesubsequent treatment regimen.

Many patients experience extreme anxiety during the detectionand diagnosis phase. Consequently, an initial psy-chosocial assessmentis necessary to identify patients' health status. In addition,this time provides an opportunity to inform the patient and familyabout support groups, social services, nutrition counselors, andother resources.

It is important to provide an initial assessment for every patientto avoid stigmatization and because of the difficulty of recognizingwho might benefit from a specific intervention.

While detection and diagnosis should occur in a timely manner,treatment is likely to last months to years. A breast cancer patient,for example, might first undergo surgery and then chemotherapyand radiation therapy simultaneously or sequentially over severalmonths. Such patients and their families will be introduced toone or more new providers, eg, surgeon, radiation therapist, oncologynurse, nutritionist, social worker.

Patients may continue to have questions or develop new problemsthroughout this period, whether about treatment, family relationships,or insurance coverage. Psychosocial resources must continue tobe available so that these concerns can be addressed in a timelymanner.

• Subacute care comprises short-term follow-up. Adaptingto life after cancer treatment takes time and support from providers,family, and friends. The risk of toxicity from treatment and recurrenceis highest just after the completion of treatment, and, therefore,initial follow-up visits are still relatively frequent. The timebetween visits will progressively increase up until a certainpoint (eg, annual examination).
• Long-term care covers long-term follow-up. As the numberof cancer survivors has grown, so has this rehabilitative phaseof the cancer process, which includes monitoring for second malignanciesand the late effects of treatment.

Psychosocial resources are also needed during short-term and long-termfollow-up, to help patients maintain their quality of life.

The 'Gatekeepers'

Both the subacute and long-term care phases of the cancer careprocess are being changed dramatically by managed care. Previously,most patients were followed by their oncologist on a long-termbasis. Now we are moving to a situation where primary care physiciansact as "gatekeepers" to specialized care.

If general practitioners are to follow cancer patients, then anew twist is added to the subacute care phase, and it will beimportant to assess the quality of follow-up provided by thesephysicians.

Most patients and their families are likely to experience somefear of recurrence for the remainder of their lives. In addition,children and young adults may develop concerns regarding theirown ability to have children as they mature. Adult patients witha family history of cancer may desire special counseling regardingthe cancer risk posed to their children.

It will be critical to provide the necessary education and/ortraining to primary care providers so that they feel comfortableand confident following cancer survivors, and so that their patientsfeel the same.

New Areas of Research

There is still a great deal to be learned about the process ofmedical care, its relationship to outcomes, and how these characteristicscan best be used to measure quality of care.

In addition, medicine is continually changing, and oncology isno exception. Advances in genetics, screening, and preventionrequire careful study to identify the most cost-effective methodsof care.

To maintain and improve the quality of oncology care, changes,whether brought about by medical advances or financial reorganization,require not only retrospective analysis but also prospective evaluation.Thus, research in a number of areas (see Table 2) is essential.

Health-care services are no longer solely under the control ofphysicians and/or patients who do not directly feel the impactof their expenditures. As managed care plans continue to enterthe health-care marketplace, it will be necessary to closely monitorand evaluate the cost-quality trade-off in oncology if we areto achieve an optimal balance between these two criteria.

The Quandary of Quality

By Cary A. Presant, MD, Series Editor

In this month's column, Ms. O'Leary and Dr. Ganz begin to examinethe issue of quality in cancer care. All oncologists recognizethe importance of appropriate diagnosis; surgical, radiotherapeutic,and chemotherapeutic planning and treatment; and prevention andmanagement of toxicity. Those issues are obvious and are the initialfocus of practice guidelines development.

But, importantly, O'Leary and Ganz focus on an underrecognizedissue: Psychosocial adaptation and comprehensive rehabilitationare critical elements of quality outcomes in cancer patients.

The authors divide cancer care into three phases, each of whichrequires assessment and interventionby experienced professionals(eg, psychologist, social worker, oncology nurse, physician, physiatrist).

In the era of cost containment, it is appealing to gatekeepersand administrators to use general medical providers to conductpsychosocial and rehabilitation interventions. However, theirlack of specialized training in the management of cancer patientsmay drastically reduce outcomes! This potential loss in qualitythreatens our specialty.

O'Leary and Ganz call for research into these issues. Will ouracademic centers and cooperative groups, National Cancer Institute,National Institutes of Health, and HMOs respond effectively byfunding and conducting these studies? The future of "quality"care in oncology depends on their commitment.