CHICAGO – One of the hardest things about having a newly diagnosed advanced cancer may be getting in to see an oncologist, investigators reported at the annual meeting of the American Society of Clinical Oncology.
When volunteers posed as patients with a new diagnosis of inoperable hepatocellular carcinoma (HCC), they were able to secure a new patient appointment only 23% of the time in 432 attempts, reported Dr. Keerthi Gogineni and Dr. Katrina Armstrong of the University of Pennsylvania in Philadelphia.
Dr. Keerthi Gogineni
Contrary to expectations, insurance appeared to be a barrier rather than a boon: Some 29% of volunteers who reported being uninsured were able to get a new-patient appointment, compared with 22% of those who said they were privately insured and 17% who said they were on Medicaid, the investigators found.
The most frequent reason (39% of cases) that the "patients" couldn’t get a first appointment was an expectation on the part of the hospital or oncology practice that patients would have all of their medical records in hand at the time of scheduling.
"That’s a lot to ask of someone who has just gotten a frightening diagnosis. Their records may be in lots of different places, and you have to be pretty savvy to say ‘I’m going to get my doctor’s notes from here, my scans from here, my labs from here, and pathology from here, and have all of that ready by the time you call them and ask for an appointment," Dr. Gogineni said in an interview.
Other grounds for refusal to schedule an appointment included inability to reach the scheduler (24% overall), referral requirements (18%), refusal to see uninsured patients (4%), need to go through a new-patient coordinator (3%), insurance type not accepted (2%), and need to talk to a financial counselor.
"It’s a huge problem right now," commented Dr. David P. Ryan, clinical director of the cancer center at Massachusetts General Hospital in Boston.
His hospital found that it has to have one phone number for new cancer patients, and that the calls need to be directed quickly to access nurses on call for each disease center, he said in an interview. The nurses talk to patients to help determine the best referral.
"What we realized very quickly is that a nonclinical person [answering the phone] just doesn’t have the right clinical expertise to find the right disease center, particularly in a big academic medical center, where everybody is subspecialized," Dr. Ryan said.
The finding that National Cancer Institute–designated centers were less likely to grant a new-patient appointment highlights the fact that many physicians at such centers are paid by salary, and may not have incentives to see additional patients above their current caseload, Dr. Ryan suggested. The study reported that appointment rates were lower at NCI-designated sites than at non-NCI sites (16% vs. 25%).
The investigators modeled their study on a paired-testing design similar to the type used to root out housing discrimination. Research assistants were instructed in how to simulate a patient with newly diagnosed inoperable HCC, and with varying insurance statuses. The study sampled 160 clinical sites, including NCI centers, hospitals caring for a disproportionate share of low-income patients, and academic medical centers in 25 of the largest metropolitan areas in the United States.
The authors recommended that "more socially nuanced and medically informed intakes may improve access to new cancer patients. Access to patient navigators at the earliest point of contact could increase access to new appointments for vulnerable patients."
The study was internally funded. Neither the authors nor Dr. Ryan had relevant financial disclosures.