Is managed care improving care of patients
with lung cancer?
In my opinion, the answer is no, care of these patients is worsening under managed care. This opinion is based upon a growing experience with patients who come to see me for second opinions. Many have had significant delays in diagnosis and treatment, mistakes in management decisions by inexperienced clinicians and delays and refusals by managed care committees to allow crucial diagnostic studies and treatments. The diagnosis and staging of lung cancer, decision-making regarding appropriate treatment as well as the actual performance of the diagnostic and therapeutic proceedures can be very complicated, and requires a long period of specialized training and practice experience to do with skill and precision. As an example, a minimum of seven years of training after medical school are required for board certification of a thoracic surgeon There is no way to short circuit this learning process. The fact that a physician is called a "gatekeeper" or is on a managed care committee does not qualify him to make these decisions or perform the treatments. And yet, this is exactly what is happening in many cases. In the traditional system of medicine, the family physician would refer a patient with suspected lung cancer to a pulmonary medicine specialist or a thoracic surgeon. The workup would be performed by experts, and further consultation and treatments, would similarly be done by specialists. Under current managed care, there is an emphasis on avoiding specialist consultation and care. This means that a relatively inexperienced physician is doing the initial workup in many cases. Furthermore, each request for a test or a consultation is potentially delayed as it goes for review by a gatekeeper or committee. Sometimes, the decisions of the primary physician are overridden by committees or MDs who have not even seen the patient. When the patient is finally referred to a specialist, there are apt to be further delays as each of the specialist's requests for permission to perform tests and procedures can be delayed in the managed care process. Delay in treatment of lung cancer is dangerous. With the passage of time, the tumor grows and spreads. If this occurs, the chance for cure can be lost. An excellent example of the consequence of delay is a report on lung cancer care in European Common Market nations. Although Great Britain has excellent thoracic surgeons, radiation oncologists and medical oncologists, English patients with lung cancer have very low chance of long term survival compared to other European nations. This information caused a scandal in England and the National Health Service has been revamped to correct the long delay between diagnosis and treatment that was perceived to be the cause of these poor results. The justification for managed care process is that it supposedly prevents the specialist from ordering expensive, unnecessary tests and procedures. In my experience, this is a false economy, as the inexperienced physician often orders the wrong tests. If delay is significant, expensive tests may have to be repeated. If the disease is allowed to progress, then the cost of care of the patient dying from lung cancer becomes very high indeed. Furthermore, if cutting costs is truly important, then it is difficult to justify the enormous salaries paid to HMO executives (as high as $32 million/year), the dividends paid to stockholders and the tremendous administrative costs in most Managed Care Organizations (averaging 20% and ranging as high as 37%). Comparable administrative costs for Medicare and Canadian national health care are well below 5%. There is nothing fundamentally wrong with managed care. All major clinics and University Hospitals have been practicing a form of managed care based on clinical practice guidelines and clinical trials for the last few decades. Such managed care, however, is managed by the most experienced physicians, not the greediest; not those with MBA degrees. Good medical care is intrinsically cost effective! Managed care needs reform badly--and soon. In the state of California, the Department of Corporations is responsible for investigation of complaints by patients who feel that are not receiving proper care from their managed care organization. Complaints can be directed to the California Department of Corporations at 800-400-0815Laws passed this year, require that appropriate action must be taken within 5 days when the patient is experiencing a condition that is threatening to his life. Other resources include the following:
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