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The July 2009 issue of Journal of Oncology Practice featured an article advocating the use of patient navigators.1 The authors suggested that patient navigators would be a valuable addition to any practice and described their use in several settings. If we are not careful, we may be witnessing the birth of a new allied health provider. Practices today cannot afford additional staff providing unreimbursed services, but this is only one of the reasons I am bothered by the navigator trend. I would divide the functions of patient navigators into two components.
Any one of us who has ever had a serious illness and received bad medical news is aware that the emotional impact of that news shuts down cognitive functioning to some degree. We tell a patient his or her cancer diagnosis, and for the next several minutes, that is all he or she hears. As oncologists, we have learned to repeat important information multiple times to overcome this emotional blockade. It is crucial to have another friendly set of ears present to help the patient recall the discussion. I feel this role is best played by a family member, loved one, or close friend, not a stranger assigned as the patient navigator.
The untrained friend or family member may get details wrong. Studies have shown that the level of health literacy is often much lower than we expect. It is the job of oncologists to educate patients and families at their levels and to realize that emotional reactions are part of patients' hardwiring. We can set up another appointment, take the time to overcome that barrier, or provide the patient and friend or family member with written materials.
Abdicating this function to a patient navigator will work only if the navigator has sufficient medical training and specific qualifications. The services provided by navigators become expensive quickly and are not reimbursable, adding to the already burdensome overhead of oncology practices. If we were to decide to employ patient navigators, how many patients could one navigator navigate? I see the development of another allied specialty, with licensing, educational, and oversight issues. I suggest that we simply encourage each patient to bring a friend or relative. We should make follow-up appointments with patients to whom we have delivered bad news and answer questions at that time. In this way, we can control the message and the expense.
The other aspect of patient navigation involves helping patients get all the appointments, tests, procedures, and information needed and ensuring that the insurance companies pay for all of these. For an uninsured or underinsured patient, this would require finding free drugs, free supplies, and free care. This is the part of patient navigation I find most alarming. We have created such an inefficient system that we need to invent a new medical specialist to help us cope with it. If our system necessitates navigators, we need a new system.
For the long term, we need portable, individually owned health insurance that cannot be canceled so patients cannot be dropped from employer-based insurance when they are no longer able to work. We need a reformed insurance market so benefits are clear to everyone and selected on the basis of service to the individual purchaser. We need an expedited system of prior authorization or, better yet, a system of automatic approval of guideline-based care. With such a framework in place, navigators would be unnecessary for the insurance function. For the short term, we need easily transmitted medical records and oncologists who communicate with referring physicians so care is coordinated at the physician level.
The patient navigator also functions as an appointment secretary for the patient, but scheduling can instead become a duty of office checkout personnel, whom patients can easily contact with questions. Everyone in the office should be a patient navigator, from the physician to front desk staff to billing personnel. The expertise required in this day and age to schedule patients for physician visits or diagnostic testing with prior insurance-company approval and proper paperwork is not a skill set one can simply assign to someone. This requires training and working with the physician and the rest of the staff.
We do not need to hire fleets of navigators. This would be insensitive to the needs of patients. On the contrary, we do need to train ourselves and our staff to help all patients get through this complicated delivery system so they can focus their efforts on getting better. Most importantly, we all should do our part to help restructure such a dysfunctional system.
The author(s) indicated no potential conflicts of interest.