Introduction: Oncology's Perfect Storm: The Next Decade

The American

Journal of Managed Care

In this supplement to , William T.McGivney, PhD, provides a masterfulsummary of the forces producing the perfectstorm for oncology services in the nextdecade: an explosion of new treatments thatare effective but costly; a cresting wave ofbaby boomers whose age increases their riskfor cancer; and a payment system that isalready making US businesses noncompetitivewithin the world marketplace. Infamouslawsuits surrounding bone marrow transplantsfor breast cancer and superb lobbyingby the oncology community have shieldedcancer services from managed care and governmentinterventions in the past. Today,healthcare managers can predict cancercosts rising at rates exceeding 20% annually,and they must find ways to curtail spendingand improve care. The following 5 majorresponses are possible in the next decade.

Transparent Measurement andEnforcement of Adherence toKnown Standards

Surgeons performing colorectal resectionsshould remove 12 lymph glands forproper staging, but the literature documentsan adequate surgery rate of only 46% of USpatients.¹ Reporting each surgeon's performancedata for this operation to promoteadherence and to inform consumers abouttheir choice of physicians is inevitable—itwill be one of many measures.

Financial Constraints forCancer Coverage

Dr McGivney mentions coinsurance as amethod for patients to participate in the costof care. Total lifetime maximum coveragemay be applied to oncology services, orcopayments may be increased for specificdrugs. Payors are reluctant to confrontappropriateness issues after the battles ofthe 1990s, and it is easier to shift the burdenof those decisions to patients. Financialconstraints will cause patients and physiciansto have frank discussions about costeffectiveness.

Emergence of National Protocolsand Registries

Adult oncology is infamous for rapid diffusionof drug use beyond US Food and DrugAdministration indications with almost nocapture of the results of these renegadetreatments. A recent review documented30% of Medicare beneficiaries receive adjuvantchemotherapy for stage II colon cancerdespite American Society of Clinical Oncologyexpert panel conclusions that adjuvantchemotherapy should not be routinelyrecommended for colon cancer.² Adoptingthe pediatric oncology community's approachto large national trials or using theCenters for Medicare & Medicaid Services'approach with specific treatment registriescan harvest information about new indicationsmuch more efficiently than currentapproaches.

Managing End of Life

As a plan medical director, I discussedfourth-line treatment for metastatic colorectalcancer to the liver with a patient. He wasreceiving chemotherapy while on an infusionof dopamine and albumin to maintainblood pressure. It was the oncologist—notthe patient—who insisted on continuingtherapy. It's an anecdote, but a commonone. We need to seriously study oncologists'behavior at the end of life and have frankdiscussions about the appropriate time toend therapy.

Ending Oncologists' Dependence on Drugs

A significant portion of oncologists'income comes from chemotherapy, and it ishardly surprising that their behavior is influencedby that fact. This is not to suggest thatoncologists should not be paid at presentlevels, but they should be paid for providingan unbiased view of treatment options andfor being an important source of informationfor patients. All of the changes listedabove will only be incrementally successfulunless the reimbursement systems foroncologists are changed.

The previous 5 changes are radical.However, it would be a mistake to assumethat the forces coming together will notcause substantial changes in the field of cancermedicine. The protection of the 1990swill not be sufficient for the next storm.

Address correspondence to: Lee N. Newcomer, MD, OncologyServices, UnitedHealth Networks, 5901 Lincoln Drive, Edina, MN 55436; email:lee_newcomer@uhc.com.

J National Cancer Institute.

1. Baxter NN, Virnig DJ, Rothenberger DA, et al. Lymphnode evaluation in colorectal cancer patients: a population-based study. 2005;97:219-225.

N Engl J Med.

2. Meyerhardt JA, Mayer RJ. Systemic therapy for colorectalcancer. 2005;325:476-487.

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