At the American Cancer Society Cancer Action Network (ACS CAN)-sponsored National Forum on the Future of Health Care, held in Washington, D.C., speakers stressed that cancer patients' access to care remains tightly linked to their ability to afford that care.
ACS CAN President Lisa A. Lacasse, MBA, said that, while millions more Americans have access to cancer care because of the Affordable Care Act, "affordability continues to be an incredible barrier." She noted that newly diagnosed patients ask two major questions: What treatment can I have and how am I going to afford my care?
"Affordability and access go hand in hand," said Gary M. Reedy, CEO of ACS. He noted that, while the cancer field has seen major advances, they do not help patients who cannot afford their care. Without health insurance, access is compromised, patients are diagnosed at later stages, the prognosis is worse, and costs are higher, said Reedy. Beyond the direct costs of care, he explained, even insured patients must cope with other cost barriers, such as transportation to treatment and lodging, if their care is given far from home. They also must cope with lost wages when they miss work due to their cancer treatment.
"I am very, very worried about our health care system," said keynote speaker and American Medical Association (AMA) President Barbara McAneny, MD, co-founder of New Mexico Oncology Hematology Consultants, creator of the New Mexico Cancer Center as the first physician-owned multidisciplinary cancer center in the state, and founder of the New Mexico Cancer Center Foundation, which provides grants to help patients with nonmedical expenses. McAneny noted that two-thirds of U.S. bankruptcies are due to medical care costs, and in two-thirds of those cases patients have insurance, but it is clearly not adequate.
McAneny put in a plea for treating patients with cancer and other chronic diseases in local community clinics by a team, not in large hospitals. "Chronic disease is not managed well in large hospitals," she said. She decried the fact that today small oncology practices are being acquired by large tertiary care hospitals, where the costs of care are usually much higher.
"We do not use our resources wisely," said McAneny, a former board member of ASCO and a past president of the New Mexico Medical Society. "If we destroy the infrastructure of cancer care delivery, we will have a serious problem." She noted that by 2026 annual U.S. health care spending could soar to $5.5 trillion (from about $3.3 trillion today). "I see this as a crisis." She said the federal government projects that the Medicare trust fund will be insolvent by 2026.
The AMA president has been interested in using data to improve the sustainability of medical practices since she was appointed to the Centers for Medicare & Medicaid Services (CMS) Practicing Physicians Advisory Council, where she served from 2002 to 2006. In 2012 she received a $19.8 million grant from CMS' Center for Medicare & Medicaid Innovation to demonstrate how oncology practices could use triage pathways to markedly lower costs while improving patient outcomes. This award, named COME HOME (for Community Oncology Medical Home), was later incorporated into CMS's Oncology Care Model for Medicare patients.
McAneny told Oncology Times that COME HOME was a health care delivery model and the OCM is a payment model. While the OCM has energized oncology practices across the country to take an introspective look at what they are doing with an eye to improvement-which is valuable-she said the problem with the OCM is that it encourages oncologists to take on financial risk-in some cases caused by factors beyond their control.
"As a practice you need sufficient reserves," she told Oncology Times, and that is why the economic risk payment model is not good for oncology. "We have no control over who's going to walk through our doors," she noted. The cancer patients who walk through those doors could be highly complex cases with multiple co-morbidities requiring very high-cost treatment.
McAneny said she is now using National Comprehensive Cancer Network guidelines and working with the AMA and ASCO to build on COME HOME and create a new data-driven model of oncology care delivery-MASON (Making Accountable Sustainable Oncology Networks).
In her keynote address, McAneny also decried the fact that the fastest growing segment of the U.S. health care system is administration, leading to burdensome administrative utilization management insurance processes such as prior authorization and incorporating required insurance drug approvals into Medicare-leading to harmful delays in necessary cancer care.
Utilization Management Techniques
Recent online surveys, one among physicians who treat cancer patients (both oncologists and primary care physicians) and the other directed toward patients and family caregivers, conducted for ACS CAN document the negative impact of utilization management techniques such as prior authorization.
The ACS CAN physician survey revealed that 70 percent or more of surveyed physicians said that utilization management techniques are having a markedly negative impact on their practice by limiting their ability to provide high-quality care and loading them with administrative burdens that siphon their time away from direct patient care. For instance:
* 56 percent of physicians said they very/somewhat frequently have to wait for the patient's insurance plan to approve a cancer treatment, test, or prescription drug that results in a delay of care;
* 43 percent said their patients are not able to afford prescription drugs for their cancer treatment or treatment side effects because of a decision by their health insurance plan administrator;
* 34 percent said their patients cannot get all of the prescription drugs that they or the patients believe are necessary because of a decision by the health insurance plan administrator;
* 34 percent said their patients are not able to get all of the tests they or their patients believe were necessary because of a health plan administrative decision;
* 29 percent said their patients could not get all of the medical care they or their patients believed was necessary because of a health plan decision; and
* 26 percent said their patients could not get all of the treatments they or their patients believed were necessary because of a health plan administrative decision.
The survey showed that nearly all physicians reported implementing utilization management techniques on a regular basis with their cancer patients' health insurance plans. Specifically, physicians said that very/somewhat frequently or sometimes they must obtain prior authorization/preauthorization of prescription drugs (96%), use a mandatory generic substitute for a drug (90%), limit the amount of drug dispensed (89%), or try a lower cost drug first (88%).
On the ACS CAN patient/caregiver survey, a majority of cancer patients and caregivers reported experiencing prior authorization requirements during their or a loved one's cancer care. Fully one in three cancer patients reported experiencing delays in their or their loved one's cancer care because their physician was waiting for approval from their health insurance plan for a cancer treatment, test, or prescription medicine.
Affordability & Access
Other invited speakers at the ACS CAN forum in Washington also emphasized the connection between affordability and access in cancer care. "Putting small practices at risk is a recipe for disaster," said Jennifer Atkins, MBA, Vice President of Network Solutions for the Blue Cross Blue Shield Association, in agreeing with keynote speaker McAneny. Atkins said that Medicare in its OCM model does put oncology practices at financial risk.
But Anand Shah, MD, Senior Medical Advisor for Innovation at CMS, said the OCM is a model "that we're very proud of. We see an opportunity for a cohesive approach in oncology." Shah said CMS realizes that the financial constraints in the OCM can be difficult for practices, as can the risk aspects. He said CMS is working with providers of cancer care to help them understand that with the OCM they are taking on financial risk.
Shah said it is hard to set benchmarks and financial targets in oncology for alternative payment models such as the OCM, especially with the increasing costs of prescription drugs. He explained CMS will continue to pursue iterations of the current OCM model, noting CMS wants buy-in from the oncology community. He added that CMS welcomes ideas and suggestions from oncologists on new payment models: "We need more outcomes measures in oncology, we need more measures that matter to patients."
Several speakers stressed the importance of prevention and early detection to avoid "crisis care" and emergency room admissions-strategies which can help keep treatment costs down. But there is little incentive for doing so, said Thomas A. Aloia, MD, FACS, Associate Professor of Surgical Oncology at the University of Texas MD Anderson Cancer Center. He also emphasized the need for HPV vaccination and screening, along with the need for obesity control in cancer patients.
"We are initiating programs in onco-obesity," he said, adding that major medical centers have an obligation to set standards of excellence for community centers. As an example, MD Anderson is partnering with primary care practices in Texas to keep care local.
Aloia and others stressed the need to initiate palliative care with cancer patients when appropriate. "We have to be really brave about this," he said. "We need to have the conversation; it's a different mode of thinking."
Given soaring U.S. health care costs, new cost containment strategies and alternative payment methods will come by necessity, predicted Omar M. Rashid, MD, JD, FACS, in Surgical Oncology and General Surgery at Holy Cross Hospital Bienes Comprehensive Cancer Center in Fort Lauderdale, Fla.
"These stressors that we're dealing with are actually going to force us to innovate," Rashid noted. He is excited about innovative methods for health care delivery, especially telehealth.
Peggy Eastman is a contributing writer.