Cancer Care as a Business
My wife is a Primary Care Nurse Practitioner. She works with a very good Internist who gives her a lot of independence in managing her patients, but always backs her up when she needs advice. She is well respected by the specialists she refers to and has always been able to discuss a patient with any one of them. Yes, there is an element of selection there, since she tends to refer to the specialists who are willing to talk to her in the first place, but that is true for any Primary Care Practitioner, NP or MD.
Today she needed a Hematology consultation on a woman she’d been following for several months. The patient has a refractory anemia and all of the usual lab evaluations have been inconclusive. She felt the patient needed a bone marrow biopsy and possibly more sophisticated lab evaluations.
Her patient was enrolled in a health plan run by BigHealth, the local healthcare juggernaut in our area. BigHealth owns seven local hospitals and another ten or so in other states. They have aggressively expanded their market share both through purchasing hospitals and practices and through exclusivity in their BigHealth insurance plans.
Recently they started a joint venture with FamousName, a well-known cancer hospital from another state, to run the BigHealth/FamousName Cancer Center. There really wasn’t a need for another oncology center in our area. The market was pretty well covered by two large oncology groups, both of whom offered Medical Oncology, Radiation Oncology and Hematology in a coordinated single referral. Plus, it was easy to pick up the phone and talk directly with one of their oncologists, discuss a patient, get some follow up or get an urgent consultation.
Enter FamousName. Their message was “We do it better”; not in so many words, but in their advertising and their attitude. They would offer all services, plus the advantage of a Team approach, combining Medical and Radiation Oncology with Oncologic surgery, nutritional consultation, and a Cancer Guide to shepherd the patient through the entire process. Nice idea, but a demonstrable advantage? I haven’t seen it. What I have seen is a longer referral process, significant delays in starting treatment, confused patients and a serious lack of approachability in the oncologists employed to deliver the care. Even the patients seldom see the Doctor. Most hands on care is done by Nurses.
So when my wife tried to call FamousName to talk to a Hematologist and explain the workup that had already been done for her patient (something she had always been able to do with the other oncology groups) she was shunted to a New Patient Coordinator. This person did not identify herself other than by first name and refused to connect her directly to a Hematologist. Instead, she took the patients name and insurance information and told my wife to fax over all labs and notes about the problem and their Internist would decide if it warranted a Hematology evaluation. Say what? Their Internist? What about the judgment of a Doctor of Nursing Practice in consultation with a Board Certified Internist with 20+ years of practice?
This is not a single incident. I have encountered the same stonewall routine when I have called personally to discuss a patient with an oncologist. I was connected to my patient’s Cancer Guide who told me she would answer my questions because the Doctor was in clinic that day.
This sort of thing may fly in FamousName’s main base of operations. They’ve been the Big Dog there for years. But out here, they have done little to attract referrals or court the local medical community. It has gotten so that no one wants to send them patients despite their Famous reputation. In order to keep their joint venture afloat, BigHealth has cancelled all their contracts with the local oncology groups giving FamousName an exclusive lock on all BigHealth patients. Now we have no choice about where to send our BigHealth covered patients.
Legal? Sure. Ethical? Maybe, if there is a definite advantage for the patient to see FamousName. But who will benefit most from a high-powered academic cancer team? The 35-year-old with a triple negative invasive breast cancer? Definitely. The 78-year-old with a Stage 1 ER/PR positive tumor? Not so much. In fact, the community was doing a pretty good job before FamousName arrived. Our oncology groups were up to date, participated in clinical trials, coordinated cancer care with surgeons and internists, and according to BigHealth’s own cancer registry, achieved better than average results compared to national standards. Once again, this was a business decision dressed up to look like innovative care and backed up by BigHealth’s dominant market share. Even then, we might have seen it as a positive. This is FamousName after all. But the arrogant attitude, the exclusivity and the inability to actually talk to one of their experts has generated hostility rather than acceptance.