Managed care introduced economics to oncology; so far, say members of the Oncology Nursing Society, the two are not getting along.
The society's position on quality cancer care contains strong language for managed care companies that focus too much on limiting costs and not enough on treating patients. The ONS position states that "a primary focus on cost by payors and delivery systems signals an onerous intention to limit access to essential components of cancer care. ONS members report alarming trends that hamper [in their eyes] the registered oncology nurses' ability to provide safe and necessary care."
A March issue of ONS News featured a cover story on the subject, which was also discussed at the society's recent annual meeting.
These trends, said the society, include the "de-skilling" of oncology nursing, which causes direct care including the administration of chemotherapy to be provided by less costly and less skilled personnel, some of whom have no demonstrated competence in the oncology forum. According to ONS, some facilities remove credentials from nurses' name tags, implying that personnel are equally qualified to provide all types of nursing care.
"Every cancer patient deserves an oncology nurse," said Linda Krebs, Ph.D., immediate past president of ONS. "In many settings, a nurse is a nurse is a nurse; they don't care if they have oncology experience or are certified in chemotherapy."
|
Withholding Care
Nancy Ledbetter, a clinical research nurse coordinator for Kaiser Permanente, believes there has been "a 360-degree turn from what it used to be it used to be that there was too much care being given and too much being spent," she said. "Now, necessary care is being withheld in order to contain costs."
Krebs agreed. A nurse since the early 1970s, she said that 20 years ago, "sometimes we treated people much longer than we needed to. Now we worry about whether we can treat people, period."
Ledbetter sees the for-profit angle as key.
"There's a big difference in for-profit and not-for-profit [HMOs]," she said. "If you have a non-profit situation, there's incentive to improve quality and expand services, and that's not there with for-profit companies."
In California, a bastion of managed care for years, a 1998 law gives patients ammunition against HMOs that deny treatment. According to Ledbetter, the law allows some patients who are denied care to request third-party review. The HMO must set up the review in a "timely fashion" and abide by the decision.
Giving patients more power can backfire, however. Ledbetter has seen at least one case in which a patient, denied a bone-marrow transplant, received it after appeal, and died soon after.
Managed care puts nurses into more ethical "gray areas," said E. J. Siegl, who recently stepped down as the coordinator of ONS' special interest group on ethics.
|
"Even something as simple as bloodwork" can be complicated, she said.
"A colleague told me of a young man with an HMO. He had a complete blood count done 6 months before and everything was fine. He came in with some problems and the HMO said he couldn't have another CBC. His mother went ballistic, and finally the oncologist said we'd do it and worry about paying him later. His platelet count was less than 2,000, so he obviously had a problem. But it took a lot of justification to the HMO, even after the [second] CBC was done."
Too Many Options?
The rise of the information age can also cause difficulties, said Siegl. "With the Internet, people see something and they want it, whether or not it will help them," she said. "Having more options makes it harder, and managed care makes it worse."
Krebs feels that patient access to information, despite problems, is a blessing. "Patients are more educated today and they want control," said Krebs. "They want to take part in what's going on and, because of managed care, they have to. They have to be their own advocates. The old `paternalistic' days have gone away, but not for the right reasons. It's not that the paternalism has been recognized as not beneficial, it's because [physicians] can't afford to offer the treatments anymore."
Cost Issues
Nurses have had to shoulder more responsibility for cost issues as well, according to both Siegl and Krebs.
"I never gave it a thought what patients paid for care before; you just submitted the bill. It wasn't an issue," said Siegl. "Now, there's not a nurse who isn't concerned about the cost of certain things. We have drug [company] representatives come in all the time and give us presentations on new drugs, and invariably the questions come up And the cost is? And the coverage is? Ten years ago we said, `wow, cool, let's order it.' "
The invasion of managed care worries Krebs in another way: she believes preventive care is getting pushed to the side.
"I run a cancer prevention screening clinic and the only way I can see people is if they can pay a fee," she said. "Managed care, to me, is supposed to be talking about prevention and health promotion, but there are people who can't pay the fee and therefore can't see me."
Because managed care "rewards" physicians by the number of patients they see, "face time" with patients has decreased drastically, said Krebs, and that is worrisome too.
"A 15-minute exam time does not allow you to teach someone how to take care of themselves," she said. "What you end up doing is treating the problem and not doing the things that would allow a patient to live his or her life in a healthier way. . . . The whole role of nurse practitioners is certainly in the area of prevention and screening and promotion, but if you're only given 15 minutes, you can't do it."
The ONS statement stresses the importance of comprehensive care, and warns that some managed care practices limit specialist visits and supportive care. A change in the managed care company can cause a change in provider coverage, forcing patients to change doctors and nurses in the middle of treatment. The relationship that had been built is gone, and the patient must start all over again. Most patients communicate frequently with their nurses, said Krebs, and when coverage changes, care and quality of life can suffer.
"Most patients don't call their doctors; they call their nurses," said Krebs. "It might be something as simple as, `My white count is low but I want to go to the movies, is that OK?' But if they don't know the people treating them, they won't do that."
![]() |
||||
|
Oxford University Press Privacy Policy and Legal Statement |