Cancer Care in the 00s: “Era of Accountability”
Authors: William T McGivney
Journal: Journal of the National Comprehensive Cancer Network (2004)

Cancer Care in the 00s: "Era of Accountability"The entry of the United States health care system into the "era of accountability" was heralded by Arnold Relman, MD, then editor of The New England Journal of Medicine, in 1987.This new era of medicine was envisioned to involve a greater emphasis and reliance on evidence in setting policies and, most especially, a system whereby provider groups or even individual providers could be evaluated on the quality, effectiveness, and efficiency of the care that they delivered.Since that widely acclaimed heralding, health care constituencies have entered this "house of accountability," but they have not made it much past the front foyer.Clearly, considerable resources and efforts have been invested in making decision-making in health care based more on evidence.Although all clinical researchers have long lived by the "evidence-based decision-making" credo, one of the two major accomplishments of managed care in the 1990s was enhanced integration of this basis for decision-making into processes for establishing clinical policies, health policies, and coverage policies.However, the brief era of managed care in the United States did not establish substantial capabilities to evaluate the quality or value of care delivered.Rather, the focus of the managed care environment in the 1990s was on micromanagement rather than on more global analyses and interventions.Managed care companies attempted to improve the value of the care that they managed for patients and employers, as purchasers, through focus on and scrutiny of individual care decisions, often at the point of delivery.Although such attempts at point-of-care management might seem daunting, the strategy actually was less overwhelming than identifying quality measures and setting up a data collection system that would indeed allow evaluation of the quality of care on a national basis.As this commentary shows, the micromanagement route was not a fruitful path.The rate of rise of health expenditures is again accelerating.The premiums charged for health insurance are increasing as they ride in the wake of health care dollar expenditures.Employers are pressuring health insurance companies, as the vendors of health care benefits, to do something.The provider side, a source of cost-savings in the 1990s, will give back no more, and providers have more clout in the 00s than they did in the 90s (except in the face of legislated federal mandates).The imperative of technologic advancement is strengthening.The population is aging.So here we are again, needing to do something before total health care expenditures account for 10%, 12%, or even 14% of the gross domestic product.Oh, sorry, we already blew through those eras while were talking and writing. Evaluating the Quality and Value of Cancer CareHistorically, attempts to formally manage and evaluate areas of medical care have focused on the so-called "low-hanging fruit" specialists in the management of asthma, diabetes, and congestive heart failure, among others.Some attempts to manage and "enhance the value proposition" of the clinical interventions for these patient populations have been successful, but in general these successful programs can best be described as large pilot projects.These programs are important, however, because they do show that, with changes in physician