Delivering High-Quality Cancer Care Charting a New Course for a System in Crisis (2013) / Chapter Skim
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8 Accessible and Affordable Cancer Care
8 Accessible and Affordable Cancer Care
Pages 309-356
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In the current cancer care system, many patients lack access to affordable, high-quality cancer care. There are major disparities in cancer outcomes among individuals who are of lower socioeconomic status, are racial or ethnic minorities, and who are underinsured or lack health insurance coverage (see discussion in Chapter 2)
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This chapter presents the committee's vision for an accessible and affordable high-quality cancer care delivery system. The first half of the chapter discusses access to care, including the importance of health insurance coverage and barriers to care for vulnerable and underserved populations.
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, which also recommended that the President and Congress develop a strategy to achieve health insurance coverage for all people. Similarly, the IOM's 1999 report Ensuring Quality Cancer Care recommended improving health insurance coverage for the un- and underinsured to ensure entry and equitable treatment within the cancer care system (IOM and NRC, 1999)
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This will enable future efforts to improve patients' access to cancer care to be narrowly tailored to address the remaining gaps in health insurance coverage. It will also be important for researchers to study the impact of the ACA on patients' cancer outcomes because patients' outcomes may be influenced by their access to care.
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This report uses the phrase "vulnerable and underserved" to describe people who may have difficulty accessing high-quality cancer care. Vulnerable and underserved populations include, but are not limited to • Racial and ethnic minorities • Older adults • Individuals living in rural and urban underserved areas • Uninsured and underinsured individuals • Populations of lower socioeconomic status In addition to health insurance coverage, other factors that impact patients' access to cancer care include (1)
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recommended improvements to National Institutes of Health (NIH) programs and priority setting to achieve greater involvement of ethnic minorities and medically underserved populations in cancer research.
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The Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities exemplifies a federal government effort to facilitate community interventions designed to improve access for vulnerable and underserved populations (President's Task Force on Environmental Health Risks and Safety Risks to Children, 2012)
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Affordable Cancer Care The affordability of care is equally important to a high-quality cancer care system. As mentioned in Chapter 2, the United States is currently facing unsustainable growth in the cost of cancer care and the rising costs of cancer care are negatively impacting patients and their families (Bernard et al., 2011; Cohen et al., 2013; Ramsey et al., 2013; Shankaran et al., 2012; Zafar et al., 2013)
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, the committee purposefully chose to frame its discussion in terms of highquality and affordable cancer care. Challenges in Cancer Care Reimbursement The most common form of financial reimbursement for health care in the United States is fee-for-service reimbursement.5 Fee-for-service reimbursement incentivizes the volume of services provided by clinicians or hospitals, but typically overlooks quality or efficiency of care (CEA, 2009; Etheredge, 2009; IOM, 2012a,c, 2013a)
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. The Affordable Care Act used the term "value" more than 200 times, yet never defined the term.
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. Porter and Teisberg suggested seven essentials of value-based competition in health care delivery, frequently called the value proposition in health care delivery (Feeley et al., 2010)
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There have been rapid shifts from 3-D conformal radiotherapy to intensity-modulated radiotherapy (IMRT) to proton beam therapy for prostate cancer, for example, even though the new technologies have not been evaluated in prospective comparative trials to determine whether they improve patient outcomes (Sheets et al., 2012; Yeboa et al., 2010)
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The Affordable Care Act narrowed, and will eliminate by 2020, the coverage gap known as the "donut hole". NOTE: Off-label use is the prescribing of drugs already on the market for an indication, age group, dose, or form of administration that has not been approved by the Food and Drug Administration.
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The American Society of Clinical Oncology's (ASCO's) Quality Oncology Practice Initiative has included a measure of chemotherapy administration in the last 2 weeks of life as an indication of poor quality cancer care (see Chapter 7 for more information on quality measures)
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Eliminating Waste in Cancer Care Driven by the IOM's estimate that more than $750 billion in health care spending is wasteful, many clinicians are taking the lead in efforts to eliminate waste and promote high-quality, affordable care. Clinician leadership in these efforts is essential to their success because clinician decisions determine how a majority of health care dollars are spent (Schnipper, 2012)
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Other professional organizations have developed lists that may be relevant in the cancer care setting as well, including the American Academy of Hospice and Palliative Medicine and the American Geriatrics Society. The committee recommends that professional societies identify and publicly disseminate evidence-based information about cancer care BOX 8-3 ASCO's "Top Five" List As a participant in the American Board of Internal Medicine Foundation's Choosing Wisely® initiative, the American Society of Clinical Oncology (ASCO)
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. Many other organizations have also reached similar conclusions regarding the need for new payment models.
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In addition, the Brookings Institution recently recommended that Medicare reimburse the majority of medical services through accountable care organizations (ACOs) , medical homes, and bundled payments (Brookings Institution, 2013)
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Ultimately, professional societies will also play an important role in changing the culture by setting expectations for medical professionalism in delivering high-quality cancer care. The ACA has established the CMS Innovation Center for pilot testing delivery system and payment models that have the potential to reduce health care expenditures and maintain or improve the quality of care (see Box 8-4)
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Initiatives to accelerate the development and testing of new payment and service delivery models More information on the CMS Innovation Center's work on ACOs and bundled payments, which are most relevant to cancer care, is available in the following section of the chapter. tion projects could be leveraged to advance innovations in cancer care delivery and payment.
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Medical home A physician practice or other provider group is eligible to receive additional payments if medical home criteria are met. Payment may include calculations based on quality and cost performance using a pay-for performance-like mechanism.
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. There is some evidence that bundled payments reduce health care costs.
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Acute care hospital stay only The CMS Innovation Center selected 48 episodes of care that are eligible for bundled payments, none specific to cancer care. Bundled payments, however, are well suited for cancer care (Bach et al., 2011; Etheredge, 2009; Newcomer, 2012)
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. The CMS Innovation Center is evaluating several types of ACO programs, including • Medicare Shared Savings Program for fee-for-service Medicare beneficiaries • Advance Payment ACO Model for certain eligible providers al ready in or interested in the Medicare Shared Savings Program • Pioneer ACO Model for health care organizations and providers already experienced in coordinating care for patients across care settings Although ACOs were initially focused on primary care, they are now being considered for specialty care, such as cancer (CMS, 2013b; Mehta et al., 2013; Punke, 2013)
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. The CMS Innovation Center awarded the Community Oncology Medical Homes (COME HOME)
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CMOH data suggest that its focus on the medical home model has reduced cancer care costs by reducing emergency room visits by two-thirds, hospital admissions per patient treated with chemotherapy per year by half, and the length of stay for admitted patients by one-fifth (Sprandio, 2012)
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. The Center for Medical Technology Policy has asserted that the pressures of growing health care costs make CED an "attractive policy mechanism for obtaining the evidence needed for making informed coverage decisions and better understanding of the subgroups and circumstances in which a technology works" (CMTP, 2013b, p.
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. Designing Insurance Benefits That Promote Affordable Cancer Care Well-designed insurance benefits could encourage patients to be involved in making cancer care affordable.
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. Almost 90 percent of Medicare beneficiaries have supplemental insurance coverage, either through medigap, employer-sponsored retiree plans, or Medicaid (MedPAC, 2012)
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government to ensure that all people have health insurance coverage. Expanding health insurance coverage is a primary goal of the ACA, which is expected to result in 25 million individuals gaining insurance coverage.
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Payers are experimenting with numerous models that could be employed to reward clinicians for providing high-quality cancer care, such as rewarding care that is concordant with clinical practice guidelines; coordinated (based on meaningful patient-clinician communication and shared decision making) ; and includes palliative care and psychosocial support throughout treatment, advance care planning, and timely hospice services (e.g., bundled payments, ACOs, oncology PCMHs, care pathways, CED, and value-based purchasing and competitive bidding programs)
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2013b. Health Insurance and Financial Assistance for the Cancer Patient.
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2011. The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery.
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2013. CBO's estimate of the net budgetary impact of the Affordable Care Act's health insurance coverage provisions has not changed much over time.
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2013a. About the CMS Innovation Center.
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Extramural research report. http://www.cms.gov/Research-Statistics-Data and-Systems/Statistics-Trends-and-Reports/Reports/downloads/oregon2_1998_3.pdf (accessed March 24, 2013)
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2012b. How far have we come in reducing health disparities?
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2012. Opting in to the Medicaid expansion under the ACA: Who are the unin sured adults who could gain health insurance coverage?
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2011. American Society of Clinical Oncology policy statement: Opportuni ties in the Patient Protection and Affordable Care Act to reduce cancer care disparities.
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. NPA (National Partnership for Action to End Health Disparities)
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1986. Inappropriate use of hospitals in a randomized trial of health insurance plans.
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radiotherapy for non-metastatic prostate cancer. International Journal of Radiation Oncology, Biology, and Physics 78(3)
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Through implementation and dissemination processes, the network aims to accelerate the adoption of evidence-based cancer prevention and control practices within local communities, focusing on underserved populations disproportionately affected by cancer. National Comprehensive Cancer NCCCP provides financial and infrastructural Control Program (NCCCP)
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financial and infrastructural support to awardees in the identification, development, implementation, evaluation, and dissemination of community based programs, as well as for culturally tailored interventions that aim to eliminate health disparities among racial and ethnic minority populations. It has prioritized efforts that focus on chronic conditions, including breast and cervical cancer.
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Minority-Based Community MB-CCOP is the component of the Community Clinical Oncology Programs Clinical Oncology Network that is primarily (MB-CCOP) responsible for engaging underserved populations and addressing health disparities in cancer through clinical trials.
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American Cancer Society (ACS) a Health Insurance Assistance A free resource that connects cancer patients with Service health insurance specialists who handle inquiries about health insurance coverage and state programs.
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Policy and Advocacy ASCO recently released a policy statement summarizing provisions of the Affordable Care Act that may help alleviate health disparities in cancer care. The statement outlines specific strategies that clinicians can apply to address the barriers to the most vulnerable patient populations accessing high quality cancer care.
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. Its first intervention is currently under way in a Mississippi community and will likely involve training lay navigators to guide cancer patients through the cancer care delivery system.
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