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The United States is engaged in a debate that will define our time. Regardless of the political outcomes, there will be dramatic changes in the US health care system. The administration has laid out three overriding goals of change: access, quality, and cost. No one argues that access to health care needs to be improved as over 45 million Americans are without coverage. Oncology patients are disproportionately affected, as our employee-based system of coverage requires a job to maintain coverage, and life-threatening illnesses often challenge continued employment.
Quality is high by many measures, but John Wennberg, MD, MPH, has shown marked geographic disparity in the way we deliver the same care across the country.1 Underlying the variation are many causes, including that providers often do not adhere to evidence-based care. Atul Gawande, MD, MPH, brought the conundrum of cost-care variation into sharp focus in a recent New Yorker.2 His must-read article, though it presents data well reported in professional and public circles, offers a compelling indictment of today's medical systems. The US President even brought it to his advisors and asked: How can this be fixed?3
Arguably the force that tightens the Gordian health care knot the most is cost. How can the cost of health care be controlled, while simultaneously addressing access and quality? Ultimately the new paradigm of care will have to make judgments on how to spend health care dollars. Physicians hope that the criteria by which those judgments are made are transparent, evidence based, and malleable to clinical context. That being said, compared with our current consumption of health care resources, inevitably there will be restrictions in spending.
Oncologists are familiar with the tensions of cost and perceived benefit. A practitioner cannot peruse reports on expensive new drugs that deliver only weeks of statistical benefit without wondering about cost. What we have not done well as a profession is to engage patients in this conversation. Without an informed patient's input, a physician cannot know a treatment's true value to the patient. Ensuring patient involvement in the decision process is a key value of practice, yet many have underlined the fact that often oncologists do not clearly outline goals of care (palliative v curative), nor do they adequately define relative benefits of differing therapies. Cost discussions are often avoided as not pertinent to life-changing treatment conversations; some even maintain that discussion of cost is somehow unethical. Clearly these attitudes and behaviors must change if we hope to have informed patients and to adapt to the coming reformed health care system.
Lowell Schnipper, MD, for the second time in Journal of Oncology Practice, reviews ASCO's work on the cost of oncology care4 and the key role of these discussions in patient care. Lee Newcomer, MD, ASCO member and medical director for United Healthcare, outlines what payers are expecting from oncologists. Paul Hesketh, MD, profiles an issue that juxtaposes cost with health care decisions regarding reimbursement for expensive antiemetics. Barbara McAneny, MD, looks at the patient navigator movement with a skeptical eye and asks if navigators are simply “unreimbursed costs … to help solve the many silos of a fragmented system.” Mike Neuss drives home the relative terms that cost and value represent.
Readers of JOP will recognize the work of Elaine Towle, CMPE, and Tom Barr, MBA,5,6 who for the third year present the only published data on the health of oncology practice. They highlight disturbing facts, such as rising expenses within the context of relatively flat revenues. Looming is the possibility that providing medical oncology services will not be practicable without other sources of income. Several practices across the country have already faced this dilemma and have either closed or been consumed into institutions or larger practices. Practices must look at these data closely, even more so in the context of the reform debate.
As the political process progresses, we hope that JOP can provide information and opinions regarding the three pillars of the administration's health care reform agenda. In truth, access, quality, and cost already drive our practice lives. JOP aspires to enlighten the ongoing dialogue with colleagues, patients, and their communities as we face changes in these areas. The editors are seeking ideas and commentary on these issues. In November, JOP will discuss quality measurement in oncology, highlighting the Quality Oncology Practice Initiative. Please contact me with any comments on these or other issues at gro.ocsa@ksedsrotidepoj.