Venting Frustrations Over Managed Care

SAN DIEGO—Just as a glacier may advance and retreat simultaneously, managed oncology care appears to be experiencing both integration and disintegration, said James L. Wade III, MD, president of the Association of Community Cancer Centers (ACCC).

Examples of disintegration, he said, include United Healthcare, whose members may have to travel all over town to receive oncology care, and the troubled Columbia HCA, which just announced that member hospitals no longer have to use the name “Columbia.”

“Integration and disintegration are occurring simultaneously, which creates tension and stress,” Dr. Wade said at the ACCC’s 14th National Oncology Economics Conference. “But over time I think you’ll see that the evolution of information systems and the development of national oncology standards for managed care will favor integration.”

The tone of speakers who presented their opinions at the managed care oncology forum suggested that a smooth integration was eagerly awaited, but a long way off.

Radiation oncology is one area that cries out for integration, argued R. Lawrence White, MD, director of Medical Education and Radiation Oncology, Washington Cancer Institute, Washington, DC. He complained about the difficulties managed care oncology patients have in receiving continuity of care and the trouble specialists have in receiving authorizations from gatekeepers.

Dr. White, who is president-elect of the ACCC, also alleged that paperwork, rather than decreasing with managed care, has actually increased. Meanwhile reimbursements could hardly be called rapid. “Red tape has doubled or tripled,” said Dr. White, who noted that secretaries must now have a high level of understanding of radiation oncology to process the paperwork.

Most important, he said, is the negative impact that managed care has had on research. At best, managed care systems are indifferent to research, and, at worst, the systems have prompted physicians to quadruple the amount of time they spend up front on trials before they can even randomize patients.

Nursing ‘Rocked by Change’

Oncology nurses also voiced their frustrations at the forum. Their field is being rocked by many changes triggered by payers’ focus on costs and delivery systems, said Linda U. Krebs, RN, PhD, assistant professor of nursing, University of Colorado. Dr. Krebs, who is president-elect of the Oncology Nursing Society (ONS), outlined some of the changes:

• Institutions are laying off their oncology registered nurses and expert oncology clinical nurse specialists, as well as senior oncology nurse leaders and administrators.
• Oncology units are closing, while nursing care is being “de-skilled,” resulting in worsening nurse-to-patient ratios. Increasingly, less qualified assistive personnel are providing patient care.
• Registered nurses are being encouraged to become generalists. “They are encouraged to think: A nurse is a nurse is a nurse, and that specialty nursing has gone the way of the dinosaur,” Dr. Krebs complained. What’s more the incentives for oncology nurses to pursue advanced training have diminished. These problems and others were recently highlighted in the ONS’s position paper on quality cancer care.

In summing up, she said, “there are many oncology nurses who are struggling and even a few who are drowning in a tidal wave of change.”

Social Services

A representative of another target of cost-cutting, social services, also weighed in at the forum. James Zabora, MSW, director of Patient/Family Services, Johns Hopkins Oncology Center, suggested that social services can actually save money by addressing psychological problems early on in new cancer patients. But there are far fewer opportunities to do this, he said. During the past year, at least 90 to 100 social work departments have been closed down across the country.

The prevalence of psychosociological distress among new cancer patients has been well documented in many studies, he said, including a new one of bone marrow transplant patients at Johns Hopkins. In this latest study, 31% of 429 patients experienced significant distress prior to their transplant. This percentage is remarkably similar to other research on depression and cancer patients.

This phenomenon is usually dealt with reactively, Mr. Zabora said. Typically, a cancer patient’s level of distress increases to a crisis before any action is taken. At Johns Hopkins, new cancer patients, as part of their registration, undergo a psychological profile. An intervention model of care is then developed.

As a pragmatic matter, managed care can benefit from this type of system because it can increase patient satisfaction numbers. Mr. Zabora mentioned one study in which psychologically distressed patients represented only 7% of the total sample but more than 33% of all dissatisfied patients. A distressed patient, the researchers concluded, was six times more likely to be dissatisfied.

Mr. Zabora believes there are economic incentives as well to integrate psychosocial services into oncology care. For example, a 1995 Mayo Clinic study on the psychological distress of patients with coronary heart disease found that high-distress patients were 15.6 times more likely to be rehospitalized and were 12.8% more likely to experience another cardiac event. The mean rehospitalization costs were $7,000 higher for the distressed patients.