Preserving Values in Managed Care

In this column, Dr. Alan Nelson, past president of the AmericanMedical Association, has provided a set of goals for oncologictreatment under managed care contracts that can be embraced byall oncologists--choice, broad scope of practice, and communication.But the real message to oncologists is: Work together with internalmedicine and primary care physicians to build a system that providesquality care of which everyone can be proud. Such cooperationis needed to help convert these treatment goals into workablecontracts with primary care groups, HMOs, and/or insurers.

The patient's choice of an oncologist is often limited by thelack of a point of service option in many contracts, and by thepayer's desire to limit risk and cost by capitating oncology servicesto the lowest priced specialist. Under managed care, the broadscope of oncology practice is encour-aged if the oncologist isproviding care on a capitated basis, but discouraged for financialreasons through utilization review committees if the payer iscontracting with the oncologist on a discounted fee-for-servicebasis. Communication between the patient's oncologist and primarycare physician is desirable, but capitalization of computerizedmedical systems to facilitate such communication is expensivefor an industry already under heavy cost-containment pressure.

The take-home message of Dr. Nelson's perceptive descriptionof our important goals might be to work collectively in organizedgroups or networks to negotiate with the primary care group orpayer to incorporate these concepts. Only if we pay careful attentionto these issues will we be able to preserve the quality that willcharacterize successful health-care reform. Indeed, both oncologistsand insurers must remember that we are not negotiating for "coveredlives" but treating real people who are suffering.--CaryPresant, MD, Series Editor

Although the health-care delivery system may change, fundamentalvalues of patient care do not, and to maintain those values, generalistsand oncologists must work together in this new era.

The health-care system is being restructured even though no federallegislation is driving the process. Managed care is transformingthe way cancer care is delivered by interposing a "gatekeeper"between the patient and the oncologist.

Many managed care plans are disrupting traditional referral patterns,and some are defining the scope of an internist's practice. Suchplans may allow a sub-specialist to provide only consulting servicesor only primary care, but not both--a distinction that is oftenunnatural.

Capitated plans may reward physicians for doing less rather thanmore. And because of plan restrictions, patients may have legitimateconcerns about whether they will be able to choose their physiciansand have access to new technology.

This is why it is appropriate to examine the relationships betweenthree vital stakeholders in the evolving system: the generalist,the oncologist, and the patient. We should try to identify strategiesthat protect patient choice, allow physicians to provide carewithout artificial restrictions, and foster superior care providedby teams.

I am convinced that the concept of the primacy of the patientis a fundamental value that is shared by all physicians, whetherthey practice traditional fee-for-service medicine, provide carein a managed care setting, or do both.

If this is a valid assumption, an examination of the competinginterests between generalists and oncologists in the growing worldof managed care becomes less contentious. We can begin to identifyhow to preserve the essential qualities of a delivery system thataccommodates current trends and meets contemporary expectationsfor care based on value.

Any successful system must recognize that patient choice and shareddecision making are here to stay. When patients decide where toreceive oncology services, they balance a desire for "thebest" with a desire to receive care in familiar surroundingswhere they can access their support system. For this reason, managedcare plans have found that members are less willing to acceptarrangements that provide referrals to "centers of excellence"located far from their homes.

Preserve Point of Service Option

The desire for choice also explains the fact that the point ofservice option is the fastest growing managed care model. Patientsare more willing to sign up with a managed care plan that providesgood benefits at a cost below traditional insurance if they knowthey have the option to receive care outside the plan if theydesire, even though they may be required to pay higher copaymentsor deductibles.

Although the managed care industry regards the point of servicemodel as an intermediate step toward "closed panel"capitation (and points to the fact that only a small percentageof insureds exercise the point of service option), patients prefera plan that does not lock them in to a restricted panel of providers.

Patients value continuity of care; they like the idea of careprovided by a team because it allows them the stability and comfortof a continuing relationship with their generalist while alsoreceiving the benefit of the experience and advanced technologyavailable from an oncologist.

Increasingly, patients rely on their oncologist to provide principalcare and comprehensive continuing care for the myriad of cancer-relatedproblems, and many oncologists have the skills to provide principalcare as well as manage the technical and highly specialized carerelated to the patient's major illness. However, many patientsstill like to know that their "family internist" ispart of the team if needed. This kind of collaboration has evolvedbecause it makes sense.

We should resist efforts by managed care plans to replace thisworking relationship with a dysfunctional set of scope of practicerestrictions that allows the patient to see the oncologist onlyas an occasional consultant or that imposes responsibilities uponthe generalist that he or she is poorly equipped to handle.

When Communication Fails

Although communication within the team is vital, optimal communicationhas not always been achieved. Generalists may not adequately communicatewith an oncologist prior to the referral, resulting in duplicationof studies or loss of confidence by the patient in one or theother. Oncologists may not adequately communicate their findingsback in a timely fashion, causing the generalist to appear tobe uninformed when approached by the patient. The patient maynot confide fully in one or both physicians and thus may not receivean optimal level of care.

The health-care system should place greater emphasis on coordinationand communication among concurrent care-givers. One potentiallyimportant advance in use by many managed care plans is a computerizedmedical records system that can be accessed readily by team membersat their own computer terminals.

The rapid restructuring occurring in the health-care system iscausing a great deal of uncertainty, which naturally leads tosuspicion and doubt. The excess capacity in the system--too manyhospital beds and too many specialists in some fields--is goingto be wrung out, and some of the wringing is going to hurt.

An absolute physician glut is on the horizon in most areas andis already established in some. It leads to an amplification oftensions around a host of issues that could be construed as representing"turf." However, I do not see managed care causing morefriction between general internists and oncologists as long aswe work together to retain these fundamental strengths: Patientchoice and shared decision making; flexibility in scope of practicerestrictions so that oncologists can practice a dual role andprovide principal care when that is in the best interest of thepatient; and maintenance of a team concept with ample communicationand with the team operating in the best interests of the patient.

We should be able to influence the evolution of the delivery systemalong these lines because it makes sense and everybody wins, especiallythe patient.

Dr. Nelson is executive vice president, American Society ofInternal Medicine. Dr. Presant is president, California CancerMedical Center, West Covina.