Delegated Model 101

How California pays for healthcare is complex and can affect the kind of care that you receive

  • According to the American Cancer Society, there were over 170,000 new cases of cancer and over 60,000 cancer deaths in California in 2020. For many living with cancer and their families, the type of care they need is not easily accessible.  
  • In California, many health insurance plans use a managed care model in which plan members, patients, must choose their doctors and hospitals from an approved network of providers specific to the medical group they have selected. Many commercial HMO (Health Maintenance Organizations) plans and almost all Medi-Cal plans operate under this model.
  • The managed care model works well for preventative care and patients with more common ailments like high blood pressure, diabetes, and heart failure.  For these conditions, medical group networks will have the necessary expertise to manage these conditions.
  • Cancer poses unique challenges to this model.  On the good side, breakthroughs in cancer research and advances in precision medicine and targeted therapies have resulted in dramatic improvements in survival from a cancer diagnosis. Few people are dying from cancer than ever before. These advances have resulted from a high volume of discoveries and insights emerging at a pace that makes it difficult for many busy oncologists to keep up. Similar to how centers of excellence are needed to treat rare conditions like Sickle Cell disease or Amyotropic Lateral Sclerosis (Lou Gehrig’s disease), or how a new sub-specialty emerged from within the ranks of Cardiology to treat arrhythmias (Electrophysiologists), cancer  has become a condition that, in some cases, requires sub-specialized, cancer type-specific expertise, e.g., for leukemia, sarcoma or a challenging colon cancer.  Published reports reflect that survival from cancer is better at dedicated and NCI-designated comprehensive centers.
  • Medical Groups and Independent Physician Associations (IPAs) are not created equally.  Unless they are very large or linked to an academic medical center, they are, by design, very unlikely to have all the expertise that is needed for rare or complex cancer challenges.  In situations where the treatment of the disease is so complex that a sub-specialist is needed, Californians should be able to seek out that expertise. For Californians with cancer, this often includes the right to seek and seamlessly receive a second opinion or life-saving treatment at academic medical centers and National Cancer Institute Designated Comprehensive Cancer Centers.
  • Cancer care is different and should be treated as such. The expertise, treatment options, and access to clinical trials that many Californians living with advanced or complicated types of cancer need to save their lives may not exist within the narrow network of a single medical group.  For this reason, we advocate for changes to the system that for select cases that require expertise that does not exist within a medical group, cancer patients be allowed to receive the care they need outside their medical group.  This process already exists for people in need of solid organ transplants or rare genetic disorders.  It is time for us to recognize that some cancer cases are just as life-threatening and require the same type of expertise.
  • When dealing with a life-altering cancer diagnosis, every moment counts.  Often, the best chance of cure is the first chance of cure. For many Californians living with cancer and their families, the current system creates receiving challenging obstacles to the care they need when they need it. The managed care system that centers care on the medical group model should continue to operate the way it does for the vast majority of its business, but can be tweaked to reduce the barriers Californians (often our most vulnerable, underserved, and minority populations) face receiving the care they require to optimize survival. Californians living with cancer and their families should spend less time fighting “the system” and facing delays, and more time focusing on health and healing. This will allow patients to spend their time and energy on fighting cancer.
  • There are significant barriers to potentially life-saving care for those who receive care through some managed care plans in California. Many of those individuals are from underserved communities and never get the care they need.  If we recognize the uniqueness of the challenges that cancer poses, these barriers can be removed without disrupting the balance of the healthcare ecosystem. Lives can be saved, value created, and affordability preserved.
  • Breakthroughs in cancer research and treatment have brought a great deal of hope for the future. That hope should be felt by all Californians, regardless of where they live or the medical group they select.
  • Ensuring access to cutting-edge treatments and clinical research trials is critical for ensuring a healthier and more just California for all Californians.