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While watching the National Football League playoff games, I was amazed by the Arizona Cardinals' stadium and the fact that the entire playing field is contained within a huge tray that can be moved from outside the dome (for sunlight and watering the turf) to inside for the games. This remarkable engineering feat (or, perhaps, the fact that I'm easily impressed) prompted me to suggest that my wife have a look. With her usual ho-hum attitude toward sports of all types, and with a smugness that can only be perfected by drivers of hybrid automobiles, she offered a rhetorical question: “If engineers can devise ways to move entire football fields from outside to inside, why in the world can't they make a car that runs well without petroleum-based fuels?” That question took all the joy out of football for me, so I began to ponder my column for the March issue of Journal of Oncology Practice. Making the shift to health care issues, the question could be rephrased: “If we, as a society, can (fill in the blank), why can't we devise a plan to provide health care coverage to all Americans?” With the inauguration of a new president, and with our country facing enormous economic and social challenges, the time may be ripe for the sweeping health care reform that has been discussed during the past two decades.
It is estimated that 47 million Americans are uninsured. Obviously, this is not an issue that is restricted to the care of patients with cancer, but is important to all of us who either provide or are recipients of health care in this country. Nonetheless, when faced with a diagnosis of cancer, the uninsured patient, the patient's family, and those who provide care are faced with tremendous challenges to ensure that they receive appropriate and timely care. I know that in my own practice in middle Tennessee, we employ a team of staff members who do nothing but work on helping uninsured or underinsured patients apply for assistance from a wide variety of public and private programs. These programs help, but there are many who fall through the cracks, and some form of universal health care coverage would be welcome by many. As with any solution to a complicated problem, “the devil is in the details,” and I'm sure that any attempt at sweeping change in our health care system will be met with wailing from many quarters. Nonetheless, a failure to act is likely to result in even greater distress. I would encourage those of you who have not already done so to have a look at a recent book by Ezekiel Emanuel, MD, PhD: Healthcare, Guaranteed. Dr Emanuel provides a thought-provoking analysis of the problem of uninsured and underinsured patients, and offers some specific ideas regarding a solution.
Any attempt at reform will require an introspective look within the house of medicine. Are we providing the right care for the right patient at the right time? Are we doing too much or not enough? Where can we, as a society, achieve the most “bang” for our health care “buck”? Should the emphasis be shifted to prevention, or early detection and treatment, rather than developing new therapies for established/advanced diseases? These questions spin off more questions than answers and will give philosophers and ethicists work for years to come.
Cancer care, specifically, is costly. The new drugs and technologies that have resulted in improved patient outcomes are tremendously expensive, and as a result can have a dramatic impact on health care economics. We are beginning to understand that we do not live in a perfect world with unlimited resources, and that we as physicians must become active participants in this complicated conversation. Tools are being developed to aid oncologists as we consider the economic impact of the care that we prescribe. Comparative effectiveness research will hopefully lead to better utilization of limited resources. The Cost of Cancer Care Taskforce established last year by ASCO has begun to grapple with these challenging problems within oncology, and I'm sure that this group will provide meaningful guidance as our organization continues to participate in the dialogue on the larger health care stage.
Bringing the focus of the column back to the Clinical Practice Committee for a moment, it is important to note that we have made a few changes to our meeting structure during January. In addition to the usual reports related to the ongoing work of the committee, we have invited guest speakers to offer our members general information regarding the current state of affairs related to the new administration and health care reform, as well as specific information related to comparative effectiveness. It is our hope that we can arm our members with information that will allow them to be more effective participants in the ongoing discussion regarding changes in our health care delivery system. It is anticipated that future meetings will be similarly structured.
Dr Cox has in the past quoted Bob Dylan in these columns. I think I'll close with words from Garrison Keillor: “Be well, and do good work.” There is indeed much work to be done.