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Patricia J. Goldsmith and Thomas Paivanas

The American standard of health care may increasingly be determined by what is reimbursed or what individuals can afford. Accountability and responsibility for choosing health care benefits are evolving and will demand that consumers are actively engaged in defining and managing their care. Concurrently, insurers are implementing new products and networks based on “quality” and “efficiency” indicators that employers are using to select payor and sometimes provider contracts. These changes are being driven by different sets of conflicting metrics used by various stakeholders in the U.S. health care system. One factor driving these changes is the aging population of “baby boomers” who, as they turn 60 this year while demanding the best health care, have been largely insulated from paying the associated costs. However, how “the best” health care is defined varies. Clearly, these metrics reflect the type of stakeholder the individual represents in the health care system (e.g., provider, employer, patient, insurer, government agency). The focus of all stakeholders in the foreseeable future is on data and information that will determine both the evolution of clinical oncology care and how it is delivered and financed. Providers will need to learn how to distinguish themselves to a more educated and engaged consumer and a more demanding purchaser (e.g., employers, patients, insurers). This summary article briefly explores developments in the following areas: • Trends in the financing and management of oncology care • Consumer-directed health care • Public payer initiatives in the management and financing of oncology care • Future challenges and future opportunities Employer-based...
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Elizabeth Danielson and Patricia J. Goldsmith

There is broad consensus that the United States' current health care system is deeply flawed with trends in spending that are unsustainable. The recent health care reform bill (Patient Protection and Affordable Care Act or PPACA) offers an opportunity for badly needed changes. Where substantial disagreement exists, of course, is where it's always found: in the details. We can agree on the need to reduce ineffective care and costs and give inefficient providers reasons to become more efficient. But how? Among the ideas gaining ground is a “restricted network” model that limits the physicians, hospitals, and other providers in the network to those viewed as less expensive, with no out-of-network coverage. Massachusetts recently enacted legislation that mandates insurers to offer at least 1 such network with a base premium at least 12% lower than that of the insurer's most comparable non-restricted network products. As noted in The Boston Globe (April 17, 2010), “Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals...—a once radical idea that is gaining traction as a way to control soaring health care costs.” Large managed care organizations are already developing or offering this type of product (The New York Times, July 17, 2010). It is widely anticipated that large academic cancer centers will also be excluded in this model. Although most hospitals and practices can undoubtedly find opportunities for efficiency, academic cancer centers face greater challenges, for reasons that include responsibility for training and commitment...