Is Cancer Meant to Be Managed?

By Frederick C. Lee
Quality Oncology, Inc., McLean, Virginia

Introduction
Managed-Care Solutions
Barriers To Cancer Disease Management
Managing Cancer Really Works
Conclusion
References

Introduction

Cancer is the second most costly and lethal disease in the United States. It is particularly prevalent in the Medicare population, affecting 8.5% of the elderly.[1] Payers spend 6% to 9% of all medical expenses on cancer treatment; cancer patients in a health maintenance organization (HMO) account for as much as 15% of all medical expenses. In the year 2001, cancer treatment across the United States is expected to cost $62 billion.[2] Moreover, due to earlier detection, reduced mortality, and the aging "Baby Boomer" population, a 50% increase in the number of people living with cancer between 2000 and 2015 has been predicted.[3]

In spite of these significant outlays, however, and the propensity of HMOs to initiate process improvement projects, the managed-care industry has, by and large, avoided a focused management of cancer. Quality Oncology, the industry leader in cancer disease management, has engaged 17 health plans over the past 5 years. Another eight plans have contracted with other disease management firms. More than 1,000 managed-care plans, however, have done nothing about cancer.

Ironically, features unique to cancer are compatible with many principles of managed care—eg, coordinating care between different providers and different institutions, keeping immunosuppressed patients out of the hospital unless necessary, and allowing patient-centric planning to dictate end-of-life treatment. But although reengineering and continuous quality improvement have been embraced by the managed-care industry in general, these components of process improvement have not been applied specifically to cancer.

Management systems are developed to facilitate more efficient processes, and produce better outcomes. The potential benefits of systematizing cancer care include:

• An ability to manage what has been documented

• Better resource allocation 

• Fewer diagnostic tests 

• Better targeted treatment 

• Patient-centric care 

Managed-Care Solutions

Patient-Centric Options

Breast and prostate cancer are excellent examples of conditions that invite patient-centric treatment decision-making. Some women with breast cancer have the option, depending on tumor size and nodal involvement, of selecting mastectomy or breast-conserving lumpectomy. Lumpectomy rates have climbed markedly across the country, from 15% in 1983 to almost 50% in 1995. Regional variations, however, persist; women with stage I or II breast cancer who received breast-conserving surgery in 1993 varied from 38% in Minnesota to 64% in Massachusetts.[4]

Men with prostate cancer generally have the option to select care congruent with their risk-taking profile and values. The American Urological Association has produced clinical guidelines that endorse the presentation of all options to men with clinically localized prostate cancer.[5] Five-year survival statistics for radiation vs surgery are consistently reported as comparable. Nevertheless, a survey conducted by Floyd Fowler, Jr., of the University of Massachusetts’ Center for Survey Research found that 91% of 504 urologists recommended surgery for a hypothetical 65-year-old male with localized prostate cancer.[6] An equal percentage of 559 radiation oncologists favored external beam radiation for the same hypothetical case. No evidence exists to suggest that either of the two approaches is superior. In fact, weighing the risks and burdens of incontinence and impotence is considered critical to making a decision.

For men diagnosed with prostate cancer and women learning they have breast cancer, the choice of advisor/counselor is as important as the selection of a physician. Without a doubt, second opinions should be recommended and paid for. Some managed-care plans have seen the value of oncology nurse advocates who equip the patient with information for just these types of predicaments, where the patient should make a decision based on what he or she values most. Efforts to educate health-care consumers, though still fledgling, will be embraced by payers as the Baby Boom generation becomes the predominant health-care consumer.

Addressing Practice Variation

The degree of success in marketing surgery vs radiation, two equivalent treatments in terms of survival in prostate cancer, is borne out by a comparison of two adjacent Florida communities, Tampa and St. Petersburg. In Tampa, where access to highly qualified radiation oncologists was ample, prostatectomy rates were 1 per 1,000; whereas in nearby St. Petersburg, they were 3.4 per 1,000.[7] Patients armed with accurate information and comparable access to resources are equipped to ensure that their needs are met and that the type of care proposed falls within current accepted practice standards.

Equally critical to an informed patient is reliable information. Though the choice of prostatectomy may be appropriate for the well-educated patient, after factoring in side effects and risks, that doesn’t mean the outcome will be favorable. Proficiency in performing the surgical removal of a cancerous prostate varies dramatically. Consistently, however, those surgeons with expertise achieved through high monthly prostatectomy volume report better outcome results, when compared to low-volume surgeons.[8] The patient who selects a low-volume surgeon may rue the decision due to complications and elevated risks, even if the choice of surgery over radiation was patient-determined and appropriate. As in prostate surgery, research has been performed on other cancer surgical procedures in which volume or specialization were critical variables.[9,10]

Evidence-Based Guidelines

Quality Oncology has determined that physicians generally practice within the boundary guidelines established for initial treatment plans. By adhering to guidelines, physicians establish a standard of care for their community and insulate themselves somewhat from legal challenges.[11] If the first course of treatment fails, however, physicians often request options outside of our evidence-based guidelines. Most patients are ill-prepared to challenge their physician or even enter into a meaningful discourse. Facilitating dialogue to address patient and family objectives, when the cancer returns or metastasizes, has a measurable effect on resource consumption.

Evidence-based clinical guidelines for breast and colon cancer were effectively introduced at the Leon Berard comprehensive cancer center in France in 1993–1994. Assessable compliance rates were measured before the initiative and again in 1995. Researchers noted improvement in compliance with breast cancer guidelines (19% to 54%) and colon cancer guidelines (50% to 70%).[12] Success was attributed to a continuing medical education program, no punitive measures, a computerized decision-support tool, and periodic reminders.

Process Improvements

Process improvement cannot occur in an environment lacking a system. Managed care is all about systematizing processes. Cancer care, however, has been largely devoid of comprehensive systems. We have witnessed improved mortality associated with early detection of cancers. Population-based initiatives that are targeted at improving cancer detection with mammography screening, Pap smears, digital rectal examinations, and prostate-specific antigen tests are excellent examples of process improvements applied to large managed-care populations. A 300,000 member northeastern HMO, noting that it could reduce mortality from cervical cancer by 75% with a Pap test, improved screening from 40.5% of those targeted in 1994 to 82.7% in 1996 through a concerted, well-executed process improvement campaign.[13]

Managed care, by its very dint, is systematically more organized than unmanaged insurance services. Thus, it should come as no surprise that researchers have quantified a statistically significant difference between the percentage of cancers discovered in late stages—7.6% of all cancers for HMOs compared to 10.8% for traditional health insurance.[14]

Deficits in reports sent by pathologists back to oncologists can often lead to improper treatment. Pathology reports can be uniformly upgraded under a consciously led effort by payers. For instance, absence of lymph node dissection documentation, estrogen-receptor status, and status of the margins of the lesion can all undermine efforts to treat breast cancer effectively.[15] To enhance the quality of pathology services, payers can leverage economic clout by concentrating all covered pathology services with one vendor or service.
Depressed breast cancer patients will fail to obtain adjuvant chemotherapy by a factor of 2:1 vs nondepressed patients with the same condition.[16] Simple screenings for depression could easily be instituted in a managed-care setting for targeted breast surgery patients, and intervention with antidepressant medication could be offered as appropriate.

Pain Management

Persistent pain greatly affects the quality of life of cancer patients and results in many unscheduled hospital emergency department visits and admissions. The pain problem is affected by a number of factors, including the mistaken assumption by many primary care physicians that becoming addicted to painkillers would be a fate worse than suffering from excruciating pain. A compelling study on pain in 522 metastatic cancer patients found that one in three lung cancer patients and as many as two in three lymphoma patients were receiving inadequate analgesia.[17]

The entire pain problem cannot be laid at the feet of the providers. In fact, many patients will underestimate their pain when asked by a third party. However, use of a consistent self-measured pain scale should balance out the process. For office practices not having daily contact with patients, this effort is problematic. But for case managers who routinely ask the same question each day, accuracy improves, leading to better proactive interventions when pain is unmanageable. This may explain why physicians are so inaccurate in estimating the degree of pain and why they underprescribe analgesics. A study published last year found physicians to be far less accurate than their nurses in assessing pain. When trying to pinpoint the degree of pain by using the same 10-point scale as the patients, only 36% of the participating physicians were accurate in their assessments.[18]

End-of-Life Care

The Health Care Financing Administration (HCFA) devotes almost 28% of its expenses to Medicare patients in their last year of life. Much of those expenditures do not serve patients well, though there is no obvious culprit. Some in the hospice movement would argue that the arbitrary 6-month "rule," which states that services may be provided to terminally ill patients with a life expectancy of 6 months or less, has discouraged physicians from making referrals into hospice. In fact, the issue may reflect more of a societal problem, where death and dying are taboo subjects that are not openly addressed.

Some oncologists still view death as a professional failure. For these physicians, discussions with cancer patients about palliative and supportive care invoke awkward self-reflection, something to be avoided. Not every oncologist has the right skill set for helping his or her patient deal with end-of-life issues. An organized system of care that relies on a variety of specialists—including oncologists, gerontologists, oncology nurses, clinical social workers, and hospice personnel—can draw the right person into these emotionally draining and difficult discussions.

Case managers who are conversationally skilled in the framing of death and dying can often open communication channels that lead to a more satisfactory outcome for all involved. By seeking out patient-specific values with respect to how a person wants to die and where, nurses have facilitated greater use of the hospice setting for a more extended stay than the perfunctory 1-week terminal visit.

Patient Satisfaction

Managed-care plans are obsessed with their patient satisfaction scores, a critical measure for determining accreditation by the National Committee for Quality Assurance (NCQA). Consequently, HMO members are routinely surveyed on their feelings about the care and attention they received from the medical delivery system. These seemingly innocuous interchanges are not nearly as prevalent in unmanaged settings. Consequently, oncologists do not always know how their patients are reacting to the care they are rendering.
In a study aimed at determining the connection between patient satisfaction and quality of life among cancer patients, researchers in Germany uncovered a variety of satisfaction problems associated with "planning of therapy, lack of involvement of family and relatives, and the level of cooperation between their treating oncologists and primary care physicians."[19] These kinds of problems can be addressed by managed-care solutions for cancer programs focused on patient needs.

Barriers To Cancer Disease Management

Only about two dozen payers have addressed cancer care comprehensively with an internal or outsourced systematic solution. Since the options to employ systematic solutions synchronize well with managed care, what are the barriers that have kept cancer disease management from being a highly successful business?

Complexity of Cancer

There are 120 different forms of cancer and 230 different diagnosis-related groups.[20] Many payers are dissuaded by the sheer magnitude of the assignment. Even when impressive returns on investment are cited, most HMO managers will opt for other disease management solutions based on a desire to start in the disease management world with a success. By tackling the most challenging disease state, the odds for success drop.

Fear of Litigation

Influencing the treatment plan of cancer patients who may die has been perceived to invite a lawsuit. Aetna/US Healthcare suffered a judgment greater than $100 million last year for a stomach cancer patient in Colorado who was deprived of a bone marrow transplant. Payers have routinely assumed that any attempt to manage a cancer patient might backfire.

Not Like Other Disease Management Models

Many of the other disease management initiatives being implemented focus on patient compliance. Working with inhalers, avoiding certain foods, getting exercise, and monitoring key physiological variables are the tricks of the disease-management trade. They have no bearing on extending life for cancer patients. In fact, much of managing cancer involves managing physicians. That challenge has become far less appealing to HMOs like UnitedHealthcare and Cigna, who, of late, have altered their provider relations objectives.

Need for Decision-Support Tools

Since so much of cancer treatment depends on the stage of the disease, having a computer system that tracks stage is critical. Currently, no claims payment systems used by payers track disease stage. Decision-support prompts and embedded clinical treatment guidelines ensure that case managers on the system are being proactive in their attempts to effect change and improve processes.

Quantifying Costs

Some patients think that the preponderance of their cancer costs consists of payments made to medical oncologists. In fact, those payments comprise no more than 12% of the total cancer expenditures for an HMO. The costs are deceiving because they are spread throughout an HMO’s payment categories. No payer has a line item for cancer costs, hence they are oblivious to its significant financial impact.

Managing Cancer Really Works

Quality Oncology has worked for 17 clients since 1996. The accomplishments we and other cancer disease management firms have achieved in this fledgling industry underscores the feasibility of successfully managing cancer.

An Ability to Manage What Has Been Documented

Efforts to manage cancer without the requisite information on the targeted population are not likely to succeed. You can’t manage what you don’t measure! For the cancer field, this maxim is particularly telling, since data on disease stage are not collected in claims systems; yet most targeted disease management solutions rely on stage information to incite action.

Better Resource Allocation

All efforts to manage cancer should focus on the misuse of the hospital setting. According to Quality Oncology estimates, hospital care represents one half of all payer expenditures on cancer. Admissions for chemotherapy can easily be shifted to the less costly outpatient setting. Poor management of nausea and vomiting associated with chemotherapy results in numerous preventable admissions. Patients often find themselves with inadequate quantities of pain medication during weekends and holidays, necessitating trips to the emergency department and often admissions to the hospital. A good deal of unnecessary terminal care takes place in hospitals, when less invasive settings could be employed. The Hitchcock Clinic’s Southern Region noted a 29% decline in cancer hospital bed days per 1,000 enrolled patients during its first 2 years of cancer disease management with Quality Oncology (see Figure 1). [21]

Fewer Diagnostic Tests

Quality Oncology has been besieged in the past year by positron emission tomography scan authorization requests. Having clinical treatment guidelines that are consistently applied has buffered our company from the overuse of this exceptional, but costly technology. In the Northeast, we had excellent results in reducing the overuse of bone scans by pulling together a group of local oncologists and letting the younger physicians impart evidence-based knowledge to their senior colleagues. Bone scans dropped 66% in the first year of our program. Requiring treatment plans with a well spelled-out course of action focuses an oncologist on delineating a plan. Treatment plans generally avoid documenting widespread diagnostic witch hunts.

Better Targeted Treatment

US Healthcare experienced success by systematically targeting women for breast lump detection, increasing their detection rate from 24% to 84% over 3 years.[22] Some researchers believe that lung cancer patients live longer when a multidisciplinary approach begins at the point of diagnosis with a presurgery, medical oncology consult. A systematically run organized delivery system could introduce a requirement for medical oncology consults prior to surgery and then test the hypothesis. With HER-2/neu-receptor status captured in an electronic medical record and systematically noted for all breast cancer patients, trastuzumab (Herceptin) could be uniformly introduced to the targeted class of women.

Patient-Centric Care

Treating cancer patients with compassion and dignity defines the field, regardless of whether patients are being managed or simply treated. Dedicated professionals abound throughout the cancer world. Yet patient empowerment has not been a valued pursuit, in part because the elderly generation that is currently dying of cancer has not been labeled as assertive, compared to their demanding children, the Baby Boomers.
We empower our cancer patients by having oncology nurses make outbound calls for the purpose of educating, counseling, and offering direction. Over time, we have learned that the oncology nurses develop meaningful trusting relationships with cancer patients, leading to difficult discussions about options, including palliation, supportive care, and hospice. This approach to end-of-life issues is largely responsible for Quality Oncology’s 285% increase in hospice use (See Figure 2) for a Florida HMO population.[23]

Listening to patients, hearing their desires and issues will influence not only terminal care decisions, but also breast surgery and prostate cancer options, to state two obvious examples already discussed. More importantly, treatment is all about the patient. Efforts that involve patients more and, in fact, make them the center of the discussion will lead to greater patient satisfaction, a key index in a more consumer-oriented health-care system.

Conclusion

The future of cancer care is transmuting before our very eyes at an accelerated pace. Systematic interventions in the new world of bioengineering will require electronic access to a variety of key clinical and physiological variables. I do not know what the future holds for cancer research, but I do know that managed care’s orientation to population-based continuous quality improvement and systematic electronic data capture will abet efforts to enhance today’s survival and quality-of-life benchmarks for all cancer patients. Since these process improvement techniques work, they are likely to be a part of all future cancer treatment solutions, regardless of managed care’s survival.

References

1. Ries LAG, Kosary CL, Hankey BF, et al (eds): SEER Cancer Statistics Review, 1973-1994. NIH Publication #97-2789. Bethesda, Md, National Cancer Institute, National Institutes of Health, 1997.
2. Quality Oncology Inc. Data on file.
3. SRI Consulting, C4: Cancer Opportunities in the New Millennium, Menlo Park, California, February 24, 2000.
4. Guadagnoli E, Weeks, JC, Shapiro CL, et al: Use of breast conserving surgery for treatment of stage I and stage II breast cancer. J Clin Oncol 16:101-106, 1998.
5. Middleton RG, Thompson IM, Austenfeld MS, et al: Prostate cancer clinical guidelines panel summary report on the management of clinically localized prostate cancer. J Urol 154:2144-2148, 1995.
6. Specialists’ biases influence what prostate cancer patients are told. Associated Press. June 27, 2000.
7. Wennberg J: The Center for the Evaluative Clinical Sciences. Dartmouth Medical School (1998). The Dartmouth Atlas of Health Care 1998. Chicago: American Hospital Publishing.
8. Yao SL, Lu-Yao G: Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst 91:1950-1956, 1999.
9. Begg CB, Cramer LD, Hoskins WJ, et al: Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280:1747-1751, 1998.
10. Nguyen HN, Ayerette HE, Hoskins W, et al: The impact of a physician’s specialty on a patient’s survival. Cancer 72:3663-3670, 1993.
11. Lee FC: Disease management in the treatment of cancer. Medical Interface 8(12):126-131, 1995.
12. Ray-Coquard I, Philip T, Lehmann M, et al: Impact of a clinical guidelines program for breast and colon cancer in a French cancer center. JAMA 278:1591-1595, 1997.
13. Quality Profiles, pp 95-98. Washington, DC, NCQA, 1999.
14. Riley GF, Potosky AL, Lubitz JD, et al: Stage of cancer at diagnosis for Medicare HMO and fee-for-service enrollees. Am J Public Health 84:1598-1604, 1994.
15. Institute of Medicine: Ensuring Quality Cancer Care, pp 93-94. Washington, DC, National Academy Press, 1999.
16. Colleoni M, Mandala M, Peruzzotti G, et al: Depression and degree of acceptance of adjuvant cytotoxic drugs. Lancet 356:1326-1327, 2000.
17. Cleeland CS, Gonin R, Hatfield AK, et al: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 330:592-596, 1994.
18. Drayer RA, Henderson J, Reidenberg M: Barriers to better pain control in hospitalized patients. J Pain Symptom Manage 17:434-440, 1999.
19. Biermann C, et al: Satisfaction with care not related to quality of life for cancer patients. Reuters. October 24, 2000.
20. Lee F: Managing oncology care. Managing Employee Benefits 5(2 winter):75-81, 1997.
21. Lee R: Accountable Oncology Associates Develops Payer-Vendor Partnership to Improve Quality While Reducing Cancer Costs. Guide to Managed Care Strategies, pp 36-42. New York, Faulkner & Gray, 1999.
22. Breast cancer disease management programs focus on prevention, treatment, patient empowerment. Healthc Demand Dis Manag 102-107, 1997.
23. Kirsch WD, Lee R: Decreasing cost and increasing patient satisfaction: the implementation of a cancer disease management program. Managed Care Interface August:65-68, 1999.

Reprinted with permission from Managed Care & Cancer - March/April 2001