Cancer Clinics, Managed-Care Firm Team Up

A Los Angeles operator of cancer clinics, in another sign of how managed health care is influencing medicine, said it has developed a method for improving the treatment of breast cancer while also restraining costs.

The announcement by Salick Health Care and Value Health Inc., a Connecticut-based managed-care firm, is part of a growing effort in the health care industry to establish clinical guidelines for physicians’ use in treating certain illnesses, particularly those that involve costly experimental procedures.

The issue of when and how to use expensive treatments for breast cancer and other major illnesses has become a point of conflict in the national debate over how to contain medical spending. Insurers nationwide have faced a number of lawsuits filed by patients who were denied coverage for treatments the insurers considered experimental.

Salick and Value Health said they have a set of clinical guidelines for breast cancer treatment developed by a panel of “internationally known academic and clinical experts.” Specifically, the guidelines focus on one of the most controversial issues in medicine: the use of bone marrow transplantation to treat breast cancer. The guidelines are intended to provide standardized criteria to help insurers and doctors decide when a bone marrow transplant would be the appropriate treatment.

The issue drew national attention in December, when a Riverside County Superior Court jury ordered Health Net, a health maintenance organization, to pay nearly $90 million in damages to the family of Nelene Fox, a Temecula woman who was denied coverage for a bone marrow transplant to fight her advanced breast cancer. She later died. Health Net recently settled with the Fox family for a lesser, undisclosed sum.

Dr. Bernard Salick, chief executive of Salick Health, which operates cancer centers at Cedars-Sinai Medical Center and other prestigious hospitals, said the Health Net case put insurers on notice that they could face significant liability when they refuse to pay for certain medical procedures.

“Managed-care companies are begging for someone to give them a clear set of guidelines” to help them decide whether to cover certain tests, treatments or drugs, Salick said.

“We can say to third-party payers, some of whom are very confused about whether or not to pay for bone marrow transplants, that . . . if a patient fits these guidelines, then that person gets a bone marrow transplant,” he said.

Dr. Chris Desch, a professor at the Medical College of Virginia in Richmond, said there is “tremendous variation in how physicians care for patients--and it’s not just cancer. . . . There is disarray in the system.”

“The guideline movement is trying to introduce some order and standards within the system,” said Desch, who is helping to develop clinical guidelines for the American Society of Clinical Oncology.

In February, two Duke University researchers reported that insurers can be “arbitrary and capricious” about covering autologous bone marrow transplants, even though they approve 77% of requests for such coverage.

Bone marrow transplants are widely used to treat leukemia, but many researchers consider them experimental in the treatment of breast cancer, a disease that strikes 180,000 women a year. A bone marrow transplant costs $100,000 to $300,000.

Dr. Armando Giuliano, medical director at the Joyce Eisenberg Keefer Breast Center at St. John’s Hospital and Health Center in Santa Monica, said cancer specialists are debating whether “morbid and expensive procedures, such as high-dosage chemotherapy and bone marrow transplants, are really superior to standard therapies and whether they are worth the cost and risk.”

The growing influence of HMOs, he said, will prompt other health care companies to develop clinical guidelines for other major illnesses. “It will probably catch steam as the health system changes from what we know it to one where costs must be carefully controlled,” Giuliano said.