The insurers have begun tightening oversight of the care provided to patients with many different types of cancer, hoping to lower expenses by experimenting with new ways to pay specialists.
UnitedHealthcare plans to announce on Wednesday a one-year project with five oncology practices, offering doctors an additional fee. The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy, which can include the most expensive drug combinations. By proposing a different type of payment structure, companies hope to lower doctors' dependence on a system that generates substantial sums for cancer specialists who routinely favor top-of-the line treatments.
Regional insurers in some states, including California, Washington and Pennsylvania, are negotiating similar limits with doctors and their clinics. WellPoint, another large insurer, is developing a way of paying oncologists to coordinate and manage patient care.
By almost any measure, cancer treatments can be exorbitantly expensive. Cancer care in the United States costs almost $100 billion a year, and medical bills for the average patient on chemotherapy can top $100,000 a year.
With the new health care law, everyone is under pressure to find ways to save money. Many specialists favor the most aggressive care even if there is little to no evidence the patient will benefit, because both doctors and patients have every incentive to spare no expense. Patients and their families often demand one last treatment. And oncologists can reap tremendous profits, sometimes earning more than half of their income on the difference between what they pay for chemotherapy drugs and what they charge the insurers for the patient's treatment plan.
Dr. Lee Newcomer, the oncologist who is heading the UnitedHealthcare program, said that yearly double-digit increases in the cost of cancer care had forced insurers to confront the issue. "Oncology, or cancer care, has been a bit of a sacred cow," he said.
With life and death questions at stake, insurers and supporters are quick to promote the new measures as a way to extract cost savings and also as a way to ensure that terminally ill patients are not subjected to unnecessary, often exhausting treatments that provide no hope.
Still, detractors worry that these changes could represent a first step toward denying patients additional treatments or the latest chemotherapy regimen based solely on the cost. In other words, they argue that even if oncologists still decide what course of treatment a patient should receive, as these new plans allow, the new effort could be viewed as a move toward rationing care at the end of life.
"We do not want to get into the realm where they are restricting treatments when they are clearly indicated," said Dr. David Eagle, an oncologist who is the president of the Community Oncology Alliance, a nonprofit lobbying group for community oncologists, who generally practice outside of an academic medical center.
"In my view, the insurance companies have the ultimate conflict of interest," Dr. Eagle said. But many cancer specialists acknowledge that the current payment system is unsustainable. "It has all the potential to bankrupt the system," said Dr. Michael Neuss, an oncologist in private practice in Cincinnati. He described the existing payment plans as "our dirty little secret."
"A lot of us want to get out of selling drugs," he said.
Companies are also springing up to develop treatment guidelines and serve as intermediaries between oncologists and health plans. US Oncology, a network of affiliated cancer doctors, teamed up with Aetna in May to develop a program to persuade doctors to follow treatment guidelines.
Another company, P4 Healthcare, is working with Highmark, a Pennsylvania insurer, and others. Cardinal Health, the large health care services company, bought P4 in July.
"There's a lot of money to be made and saved," said Dr. Peter Bach, a health policy analyst and physician at Memorial Sloan-Kettering Cancer Center in New York, who also served as a consultant to the federal Medicare program.
For example, doctors could choose less expensive therapies. When an oncologist considers different treatments, "it's hard not to look at price differentials," Dr. Bach said. In treating one type of lung cancer, for example, doctors can select from as many as eight treatments that are generally considered appropriate. Their costs under the Medicare program range from about $1,300 to $7,000 a month.
Dr. Marcus Neubauer, a doctor near Kansas City, Kan., whose practice is affiliated with US Oncology and one of the five involved in the UnitedHealthcare experiment, pointed to the effect of rising costs when people are required to pay a large amount of their overall medical bills. "It's not just a payer problem; it's a patient problem, too," he said.
Some insurers say there may be savings if doctors just follow standard treatments, rather than a variety of alternative regimens, for patients with the same type of cancer. "In medical oncology, there is tremendous variability in the way care is delivered," said Dr. Lonny Reisman, Aetna's chief medical officer.
Aetna and US Oncology recently compared what happens when doctors treating certain lung cancer patients followed guidelines with what happens when the doctors did not. According to the analysis, treatment costs over a 12-month period were 35 percent lower when doctors adhered to standards, with no effect on patients.
Aetna is now working with about 250 doctors in Texas and says it plans to expand the program next year to include even more cancer specialists in its network. In California, Blue Shield joined with Hill Physicians Medical Group to treat a group of state workers in Sacramento. Local oncologists are being rewarded for saving money, but Hill has made sure the doctors are still getting paid even if the patients' care becomes very expensive.
Joseph P. Newhouse, a health policy professor at Harvard who has studied how the Medicare payment system affects doctors' choice of treatments, suggested that some payment options might give doctors an incentive to stop treatments if they lose money or make too much by not actively treating patients. "Wherever you set" the incentives, he said, "you're going to make errors."
In the UnitedHealthcare program, for example, oncologists still get a fee even if the patient is not getting chemotherapy. To make sure no one is stinting on care, the oncologists involved review one another's treatment decisions and results. The doctors involved in the program say there is no danger that they will fail to treat patients who would benefit from another round of chemotherapy.
"These are patients we know by name," said Dr. Bruce Gould, an oncologist outside Atlanta who is one of the participants. "As medical oncologists, our goal is to take care of these patients and keep them living as long as possible."
Specialists do worry that the complexity of caring for cancer patients may make any hard-and-fast rules about treatments difficult. Dr. Neuss offered an example involving two drugs, with the cheaper one requiring patients to undergo a much longer treatment than the more expensive choice. "What's the patient's time worth in that equation?" he asked.
Dr. Newcomer of UnitedHealthcare acknowledged that some trade-offs were not clear cut but could be judged on factors like the difference in cost between the drugs — is it a few hundred dollars or a few thousand? "I think that's a perfectly legitimate debate," he said.
http://www.nytimes.com/2010/10/20/health/policy/20cancer.html?src=me&ref=health
