2nd opinion service raises questions about quality, who controls patients
2nd opinion service raises questions about quality, who controls patients
Is it about quality or utilization rates and money?
A new quality review program that provides cancer patients with a second opinion from one of the nation’s leading cancer institutes without, as a rule, seeing the patient is getting mixed reviews among oncologists and quality professionals.
Oncologists question whether a program that bases second opinions solely on pathology reports and medical records from afar can truly offer patients sound medical advice. Quality professionals, on the other hand, say the program could broaden disease management knowledge in smaller facilities and introduce them to the latest treatment options.
Despite conflicting views, however, this program is likely to catch the eye of other disease management experts who also hope to cash in on their own expertise.
The service in question is the Cancer Care Quality Review. The review, which debuted in August, is part of CareCounsel, the San Rafael, CA-based health and family care assistance program.
Under this program, offered either through an employee benefits package or individually, cancer patients and family members can turn to New York City-based Memorial Sloan-Kettering Cancer Center oncologists for second opinions and oversight in top quality treatment options and disease management.
CareCounsel’s president and CEO Larry Gelb says the program was born out of patient concern that quality care has fallen prey to managed care’s stringent cost constraints. "Patients are really becoming concerned that their [HMOs] may not be providing the best care," Gelb notes. "With the Cancer Care Quality Review Program, patients from all over the country can have one of the top cancer centers review their cases. This helps put them in control of their care. It gives them piece of mind and lets them know if they are being treated properly under their primary care physician."
While one oncologist says he understands the consumer demand for quality care, he worries that a long-distance program could backfire and create an entirely new set of problems in terms of health care.
"I don’t think many oncologists would feel comfortable with a program like this," says Alex Hantel, MD, director of Edward Hospital Cancer Center in Naperville, IL. "A good oncologist won’t have a problem with a second opinion, but they don’t want that opinion done in a vacuum either. I think it’s extremely difficult to offer a second opinion without even seeing the patient," he adds. "Most second opinions are based on records, pathology reports, but most of all, the patient. Without having every patient there, a big piece of the puzzle is missing. And I don’t see how that can [constitute a quality review]."
While one Sloan-Kettering source say he understands why oncologists may have initial concerns, he says that the program does not jeopardize a patient’s well-being, but rather promotes top-notch treatment.
"We want to make absolutely sure that patients aren’t being incorrectly treated and diagnosed," notes John Gunn, executive vice president and CEO of Sloan-Kettering. "I think what this program means for the consumer is an ability to get a second opinion from a doctor who treats the disease day in and day out, not just a doctor who only does second opinions."
Gunn says the cancer center is confident that its oncologists can offer a solid review based on the reports. "Presently, 15% to 20% of the pathology reports we see are not [adequate]. In those cases, we can usually go back to the pathologist to obtain [additional results]," Gunn adds. "Occasionally, though, we may ask to see the patient if the results are questionable. We won’t give a second opinion unless we’re comfortable with it."
How does the program work? Once a cancer patient receives an initial diagnosis and treatment plan, that individual can hand his or her case over to CareCounsel. CareCounsel’s staff gather all applicable medical records, including the patient’s pathology reports, X-rays, MRI scans, and an up-to-date report of treatments offered and performed. Those reports are then sent to Sloan-Kettering where they are analyzed by two or more oncologists. The Sloan-Kettering specialists assess the accuracy, thoroughness, and overall quality of the diagnosis and treatment by the patient’s provider and issue the patient a quality report based on their findings.
Quality reviews don’t come cheap
But pushing the envelope for quality care does not come without a price. CareCounsel clients can expect to fork over $800 to $1,350 per review, depending on the case and the number of reports being analyzed by Sloan-Kettering oncologists.
Still, one outcomes expert believes cancer patients and smaller hospitals alike could benefit from a program like this one. "I think this program is a good idea overall, mainly because Sloan-Kettering does have a lot of experience in cancer [research and treatment] and is very up on the literature," notes Janice Schriefer, RN, MSN, MBA, CCRN, director of outcomes management for Butterworth Health System in Grand Rapids, MI. "If I had cancer, I’d love to know what Sloan-Kettering thought."
"It’s tough for many small hospitals to keep up with new [treatment options]," Schriefer adds. "If Sloan-Kettering makes a different recommendation, it gives the patient’s [initial cancer care provider] the chance to learn from it. Any ethical doctor who is comfortable with a treatment decision or diagnosis shouldn’t mind. And as long as the smaller hospitals can provide that quality service, they will be favored [by the payer]."
But what if, despite Sloan-Kettering’s feedback, a patient’s care provider still stands firmly behind the original diagnosis and treatment decision? Once again, CareCounsel steps in, Gelb explains.
"We help the patient present the report to the doctor and even work with the patient’s health plan to gain authorization for [additional treatment] at Sloan-Kettering, if necessary, or through the patient’s [initial] cancer care doctor," he says. "We take the worrying out of the process for the patient. We even have people here to help with an appeals process, if necessary."
Hantel worries, however, that cancer patients are unnecessarily putting all their eggs in Sloan-Kettering’s basket and that the program is a marketing ploy that takes advantage of a desperate group of patients.
"Sloan-Kettering is not the only arbiter of proper cancer care. It does have some very specialized areas. But there are other facilities like the Mayo Clinic, Cleveland Clinic, the University of Madison, and others that work under [high] standards of care," Hantel says. "It seems this is just a way for Sloan-Kettering to get its name out there some more, and it is targeting a very vulnerable group of patients to do it. That concerns me."
Gunn says the hospital is not interested in stealing patients, but rather hopes to provide other facilities with valuable input regarding cancer treatment options. "We are at about 100% occupancy, so we’re not interested in taking more patients. In fact, we’re going to keep an eye on our [quality report] volume. If we get to the point where we don’t think we can [handle the load], we may have to ask CareCounsel to get other [leading cancer centers] involved as well," he explains.
"Cancer treatments are continuously changing, so I think other facilities can only benefit from added knowledge. The sad reality is that too many patients are being incorrectly diagnosed and treated," Gunn continues. "And if just one of those factors is off, that patient’s chances of survival drop significantly." At press time, only five cancer patients were currently taking advantage of the quality review service.
In addition to sharing knowledge, Schriefer also believes that the Cancer Care Quality Review Program could help fight the problem that faces so many of the nation’s health care facilities: underutilization for the sake of cost reduction.
"The problem with capitation is that it makes all physicians look at ways to cut down on procedures in order to be more [cost-effective]," Schriefer says. "Some may also argue that Sloan-Kettering is overutilizing. But don’t you think there’s more danger to providing too little?"
[Editor’s note: Readers, tell us what you think. Would you welcome a program like CareCounsel’s Cancer Care Quality Review? Do you think a program like this could have negative effects on a patient’s disease management program? Send comments to: Julie Johannsen, Editor, QI/TQM, P.O. Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5447 or e-mail [email protected].
For more information, contact Larry Gelb at CareCounsel, 68 Mitchell Blvd., Suite 200, San Rafael, CA 94903. Telephone: (415) 472-2366.]
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