who receive care within Medicare's fee-for-service (FFS) system, where consumer-oriented quality measures are generally less available.

Consumer-oriented quality initiatives have focused largely on helping people choose among managed care plans. For those with the opportunity to opt into managed care or switch plans, there is a wealth of information that, over time, is beginning to address meaningful issues for those with chronic illnesses such as cancer (see descriptions of the National Committee for Quality Assurance [NCQA] and the Foundation for Accountability [FACCT] later in this chapter).

A new generation of consumer surveys about health plans is now available that go beyond simple ratings of satisfaction (Cleary et al., 1997). Consumers are asked to report on specific experiences in obtaining health care, for example, difficulty in obtaining referrals. If a plan is large enough, cancer-specific ratings or at least the experience of individuals with chronic illness or functional limitations—could be provided to those making health plan choices. Here too, standardized measures are being developed to allow managed care and FFS comparisons (http://www.ahcpr.gov/qual/cahpfact.htm). The Health Care Financing Administration (HCFA) has posted on the internet (www.medicare.gov) some results of these consumer satisfaction ratings for Medicare beneficiaries in health plans, along with comparative plan ratings on indicators such as mammography use. HCFA plans to survey those who have disenrolled from health plans to provide information to beneficiaries on why people leave health plans (Medicine & Health, 1999).

Most individuals with a new diagnosis of cancer find themselves in an insurance system that they must live with, at least in the short term. At this point, many people have little flexibility in terms of their insurance plan, although they are usually able to choose among physicians within their plan and among institutions covered by their insurer.

Choosing Physicians and Hospitals

In choosing a physician, one basic piece of information is whether the physician is certified by a cancer specialty board, which requires completion of an approved training program and passing a rigorous written and oral exam about cancer care. Other potential indicators of physician quality of relevance to consumers might include: history of disciplinary action, hospital admitting privileges, volume of cancer patients treated, number and credentials of support staff, and the personality and demeanor of the provider and staff. Not all of this information is readily available, and as described in Chapter 5, good evidence is lacking to support the link between these indicators and outcomes of care. There are, for example, very few studies of the effects of physician specialization on outcomes of care, so although board certification has some intuitive appeal as a quality measure, the effect of certification on outcomes of care is virtually unknown.

For hospitals, there are several indicators of the range of services available (e.g., research programs), structure (e.g., size as indicated by annual hospital discharges), and to a limited extent, the quality of cancer-related services (e.g., appropriate use of diagnostic tests):

  • The American College of Surgeons' Commission on Cancer (see below) has standards for approving hospitals.
  • The National Cancer Institute (NCI) designates cancer centers for support of cancer research, and these centers are affiliated with a wide range of small and large hospitals. Treatment at participating hospitals means patients could have access to clinical trials (see Chapter 3).

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