Shifting power: is the consumer next?

Consumers are not likely to act as patients much longer. They'll demand the same level of information and service they receive from every other sector of the economy. Dozens of new, innovative companies are changing the health care coverage purchasing methods to allow more control and accountability for consumers. They can be broadly categorized into four groups: (1) the "Charles Schwab" clones, (2) spot markets, (3) "make me a doctor," and (4) personalized health care systems. Physicians become directly accountable to their patients in these new models. But choosing health plans may not be enough. It is only a matter of time before consumers demand the right to build their own customized heath plans using the defined contributions from their employers. This article describes the benefits of personalized health care systems and why the death of medical necessity is not far away.

Role of technology assessment in health benefits coverage for medical devices.

With the profusion of new medical technology, managed care organizations are faced with the challenge of determining which medical devices and services warrant health benefits coverage. To aid in this decision-making process, managed care companies turn to technology assessment, a process that differs from the Food and Drug Administration's review of medical devices. Health plans typically use a structured approach to implementing coverage requirements in employer group benefits contracts and use technology assessment to evaluate the scientific evidence of effectiveness to support coverage decisions. Also important is the societal context for decisions regarding coverage for new technologies and the options being considered by policy makers for accountability in technology assessment by private insurers and health plans.

Deodorants, value, and performance.

For the health-care market, like the deodorant market, the message is clear: Add value or your product will not be competitive. For physicians of all specialties, the best way to add value is to measure and improve performance. Performance measurement is critical to improvement in health care. Without measurement, there can be no improvement in quality. Without improvement in quality, there is no added value. Oncologists can take at least two actions to add value for their health plans: (1) measure practice performance and demonstrate a quality improvement; and (2) become the personal-care physician for cancer patients.

Cardiologists' practices compared with practice guidelines: use of beta-blockade after acute myocardial infarction.

OBJECTIVE: Our purpose was to measure cardiologists' level of adherence to guidelines for long-term use of beta-adrenergic blocker therapy after acute myocardial infarction. BACKGROUND: Beta-blocker therapy after acute myocardial infarction has been shown to reduce the incidence of reinfarction and associated mortality. To learn about cardiologists' use of this therapy after hospital discharge and their level of adherence to American College of Cardiology guidelines, we analyzed insurance claims from 17 network-model health plans located throughout the United States. METHODS: The study group included 150 cardiologists who had contracts with one of the health plans and their 280 patients who were plan members (excluding Medicare enrollees) and received inpatient treatment for acute myocardial infarction that did not include revascularization during 1992. These patients accounted for 307 separate hospital admissions. Insurance claims were used to measure beta-blocker usage and to identify possible contraindications. RESULTS: Forty-three percent of the cases (131 of 307) involved apparent deviations from the guidelines: 11% of cases (35 of 307) involved possible errors of commission (beta-blocker given in the presence of a contraindication) and 31% (96 of 307) errors of omission (beta-blocker not given in the absence of a contraindication). Of the 185 patients who were eligible for the therapy (no contraindications), only 48% (89 of 185) were treated. CONCLUSIONS: Cardiologists currently exhibit a low level of compliance with their specialty's guidelines for postinfarction beta-blockade. Slightly fewer than 50% of the study patients who were eligible for treatment actually received a beta-blocker after hospital discharge. This result, combined with the drug's known level of effectiveness in preventing recurrent myocardial infarction, suggests that increased use could avert approximately 1,900 deaths annually nationwide.

Phase I study of divided-dose vinblastine in advanced malignancy.

Thirty-one patients with advanced malignancy received vinblastine as an iv bolus at 0 and 48 hours of a 21-day cycle. Divided-dose vinblastine may be given with acceptable toxicity in heavily pretreated patients; leukopenia and neuropathy were the dose-limiting toxic effects. One patient with breast cancer and one with ovarian cancer responded. Serum vinblastine levels with this program approximate those achieved by a 5-day continuous infusion of vinblastine in standard dose.

Aminoglutethimide-induced bone marrow injury. Report of a case and review of the literature.

A patient with advanced breast cancer who died of septicemia associated with aminoglutethimide induced agranulocytosis, is reported. Aminoglutethimide is effective and widely used in the treatment of metastatic adenocarcinoma of breast. Thrombocytopenia, leukopenia, or pancytopenia have been reported as complications of therapy in 1.6% of 1345 patients treated in recently published clinical trials employing aminoglutethimide; and this may underestimate the true incidence of this drug side effect. Implications for clinical research and clinical practice are discussed.

Sclerosing variants of follicular center cell lymphomas presenting in the retroperitoneum.

A study of 22 patients with sclerosing variants of follicular center cell lymphoma (FCCL) presenting as a retroperitoneal mass is reported. These FCCL variants comprise 74% of retroperitoneal non-Hodgkin's lymphoma presentations. A partial intranodal follicular growth pattern was present in each case, and marked sclerosis of a distinctive pattern was associated with extensive perinodal lymphomatous infiltration. Small cleaved cells (SCC) predominated in five cases, large cleaved cells (LCC) in 14, and large noncleaved cells (LNCC) in three. Eighty percent of patients with SCC predominance were Stage I-II, compared to 50% of those with LCC predominance; all three LNCC cases were Stage IV. High stage was attained primarily by renal invasion or infiltration out the mesenteric root into gut or omentum; only three patients had biopsy proven extraabdominal disease. Combined modality therapy achieved an 88% complete or partial remission rate in patients with SCC and LCC predominance; all three LNCC patients died.