Chapter 12: Reimbursement for General Medical Oncology; the Value of Generalists in a Field of Subspecialties
Dr. Fisch begins this segment by explaining the challenges of arranging insurance reimbursement for services and value that general medical oncologists deliver. He also notes that losing connection with the GMO clinician can be very setting for a patient, and he gives examples of problems that can arise.
Dr. Fisch also explains that “people’s health stories are not completely oncology.” They often have co-morbidities and challenges can arise in bringing together specialists to fully treat a patient. In a fragmented system organized by subspecializations, often the patient must serve as “project manager” of his or her own care.
Next Dr. Fisch talks about the value of having a generalist perspective in this situation. He then talks about LBJ Hospital. He comments that eventually generalists will define the pathways into a patients care and then specialists will take over.
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Michael Fisch, MD:
But you’re right, it creates sort of a new field and it creates some other dilemmas that are also financial dilemmas. So to the extent that medical oncologists get paid for what they do, they do not get paid in the same way. Or let’s just say their keepers, you know, the systems that hire them, either them individually or their groups or their organizations, are not being paid a flat rate for all their navigation, so they get best reimbursed or their systems are being most reimbursed during the part of the journey that involves initial treatment planning, lots of use of laboratory and diagnostic tests and multidisciplinary planning, and then the giving of the treatment. In fact, the pay is tied to the treatment itself, which is a bit of a problem that people are trying to figure out how to reform. But in this post-treatment part of the ride, there’s often a fair amount of complexity but not much reimbursement, and so that becomes a problem. People who know more than I do about administering cancer care from the financial administrative point of view will sort of point out that, in a sense, the margins become negative after a certain part of the ride, so that there becomes an organizational incentive to say, “Why don’t we do this part, and then why don’t we see if somebody else will do the part that’s margin-negative for how we’re structured and how our costs are put together and such.” And the problem there is that part of the ride’s not margin-positive for anybody, so you don’t sort of create an industry around that. You have to figure out how that’s going to happen. From the patient experience of that entire ride, it can be very unsettling to realize that as time goes by that there can be gaps. Sometimes there are significant post-treatment problems, things that started during treatment and never went away. The jargon around that is to call them chronic effects. Might be painful numbness and tingling from nerve damage due to treatments that started during the treatment and never disappeared, or they may be late effects, which are more or less—a late effect is like a little time bomb that goes off later. So if you develop a leukemia as a consequence of treatment that pops up three or five or seven years down the road, that’s kind of a late effect. Or emerging heart failure or ischemic heart disease some years after the treatment, maybe it was a little bit chronic in terms if it was theoretically detectable, the biology, the damage was already there on a chronic basis, but the late effect of the worsening of it or the clinical emergence of it to where you notice it, you know, it was a sort of submerged problem that surfaces years down the road. So there’s some complexity in there, some subtleties in there. And the other thing is, you know, people’s health stories are not purely oncology, right? We tend to put on our oncology-colored lenses and we look at the patient as a colorectal cancer patient, pre-treatment, during treatment, post-treatment, but that person is a person who has many dimensions, including other health problems. They are also a person with diabetes, a person with arthritis, a person about to acquire other comorbidities, memory loss or what have you, and the cancer part of the story is one piece of it. So then the issue is, well, how is this all integrated in terms of caring for that person? Do the oncologists stay with oncology-colored lenses and then ask a primary care doctor to coordinate all this stuff? Or how do you bring it all together? I think our system has been very fragmented. It rewards subspecialization, and people are really attracted to subspecialists, right? My doctor knows more about the heart than anything else, and I have a heart problem, I want to see somebody who knows a lot about that. Or same idea for any kind of specialty, including cancer. But that has been problematic in this country with respect to coordination of care, fragmentation of care, and more burden being shifted onto patients and families to sort of be a stronger member of their own healthcare team and really the project manager of their own healthcare. They’re having trouble delegating that project management piece, but that project management piece takes medical knowledge oftentimes, and quite a lot of time, and there are consequences to getting that part not right. But anyway, these are the sort of things. So even within the field of oncology, you know, people are very attracted to subspecialty care. So I have breast cancer, I want somebody who does breast cancer all day long and knows everything about breast cancer and talks about every little thing that’s happening in breast cancer. I only feel safe if that’s the way it is. And there’s something appealing to subspecialty care like that, but there are some limitations there as well. So it is useful to have a broader perspective on cancer care to be able to connect the dots about trends in patient care and supportive care and the biology of cancers that cut across disease. So being super narrow is appealing only but so much. So in my department, the Department of General Oncology, we developed out of an appreciation for having some flexible and versatile oncologists who are needed in settings where there’s a case mix, so to speak, people with different diseases coming to the same clinic. If you’re in one clinic at Lyndon B. Johnson General Hospital in Houston, a county safety net hospital, now called the Harris Health System, you don’t have sort of the Breast Cancer Clinic, the Colorectal Clinic, etc. You have the Oncology Clinic, and flowing through there are people with different diseases. So unless you’re going to have a bunch of specialists just trying to pick off the specific little case mix, which is sort of their specific area, that’s very inefficient. It’s more efficient to have people who are able to see whatever those patients are. Or if you are in a practice in Lynchburg, Virginia, you don’t need a colorectal specialist. You need general oncologists who may be in touch with colorectal specialists when they’re learning about how to apply themselves or following pathways that have been constructed by specialists. So I think we’re getting to a world where you need fewer specialists who are creating highways that are navigable by general oncologists, but there’s controversy around that, so it depends what you’re trying to do. Some people just find that sort of efficient and sensible at some level, but it doesn’t work for the marketing department, you know, and to differentiate yourself from the other generalist pack, you try to be more specialized and appeal to people who are attracted to the super specialist models.
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 12: Reimbursement for General Medical Oncology; the Value of Generalists in a Field of Subspecialties" (2015). Interview Chapters. 835.
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