Delivering High-Quality Cancer Care Charting a New Course for a System in Crisis (2013) / Chapter Skim
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2 The Current Cancer Care Landscape: An Imperative for Change
2 The Current Cancer Care Landscape: An Imperative for Change
Pages 43-90
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the challenges and opportunities in cancer care, including trends in cancer treatment, unique considerations in treating older adults with cancer, unsustainable cancer care costs, and federal efforts to reform health care. The chapter concludes with a section outlining the key stakeholders who will be responsible for transforming the cancer care delivery system, setting the stage for the report's subsequent chapters, which address the committee's recommendations for overcoming challenges to delivering high-quality cancer care.
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population getting older, the older adult population is getting older. Increasing Diversity of the Population Growing racial and ethnic diversity in the United States are important demographic trends influencing the delivery of high-quality cancer care.
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population will increase from 305 million to 365 million (a 19 percent increase) , while the total cancer incidence will rise from 1.6 million to 2.3 million (a 45 percent increase)
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(74.0) African American alone 35,818 39,909 44,389 48,728 52,868 56,944 (12.7)
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. In addition, the cancer incidence rate is expected to grow faster among racial and ethnic minorities than for Whites (Smith et al., 2009)
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© 2009 American Society of Clinical Oncology. All rights reserved.
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. These disparities in people with lower SES are often attributed to differences in cancer preventive behaviors, health insurance status, and an inability to access and afford timely screening and appropriate follow-up care (ACSCAN, 2009)
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. In addition, the number of cancer survivors over the age of 65 years is expected to increase at a faster rate than for any other age group; by 2020, 11 million cancer survivors will be older adults, a 42 percent increase from 2010 (Parry et al., 2011)
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Individuals with low SES often lack access to preventive care or cancer treatment due to the high cost of care, lack of health insurance, poor health literacy, or because they live in poor or rural areas that are geographically isolated from clinicians (ACS, 2011)
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. From 1999 to 2008, overall cancer death rates appreciably declined in every racial and ethnic group except American Indian and Alaska Native populations (Eheman et al., 2012)
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According to one study, racial and ethnic minorities and nonEnglish speakers were less likely to report that they had received excellent or very good cancer care than were Whites, and analyses found that a TABLE 2-4 Death Rates by Race in 2006-2010 from 18 SEER Geographic Areas Death Rates by Race and Ethnicity Race/Ethnicity Male Female All Races 215.3 per 100,000 men 149.7 per 100,000 women White 213.1 per 100,000 men 149.8 per 100,000 women African American 276.6 per 100,000 men 171.2 per 100,000 women Asian/Pacific Islander 132.4 per 100,000 men 92.1 per 100,000 women American Indian/ 191.0 per 100,000 men 139.0 per 100,000 women Alaska Native Hispanic 152.1 per 100,000 men 101.2 per 100,000 women NOTE: SEER = Surveillance, Epidemiology, and End Results program.
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These advancements, however, have coincided with unsustainable growth in health care spending -- spending that is likely to be exacerbated in the future by a cancer care delivery system overwhelmed by many more patients and an increasingly complex patient population with multiple comorbidities. Congress, recognizing that national changes are needed to address these challenges, passed major health care reform legislation as well as a number of other policy initiatives in recent years.
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. Older patients -- especially frail patients, those with organ dysfunction, or those with poor health status -- are often excluded from cancer clinical trials, and the impact of cancer treatment on physical or cognitive function is typically not captured in clinical trials (Hutchins et al., 1999; Talarico et al., 2004; Unger et al., 2006; Yee et al., 2003)
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. Unsustainable Cancer Care Costs In the United States, the rising costs of health care is a central fiscal challenge (CBO, 2012b; IOM, 2012a; NRC, 2012; Sullivan et al., 2011)
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Periods of stress, such as stress induced by cancer and/or cancer treatment, can further impact an individual's physiological state. For example, older adults often have increased bone marrow fat and decreased bone marrow reserve.
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For example, older adults are at an increased risk for mucositis, which impacts an individual's ability to maintain adequate nutrition during cancer therapy. Weight loss in cancer patients is associated with poorer chemotherapy response rates and poorer survival (Dewys et al., 1980)
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. Social support plays a vital role in the psychological functioning of older adults and can mitigate the psychological impact of stressful life events, such as a cancer diagnosis and cancer treatment (Kornblith et al., 2001)
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has estimated that health care spending will grow at an average rate of 6.2 percent annually, driven by a number of factors, including the aging of the population and implementation of health care reform (CMS, 2013b)
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Health care costs are a critical challenge to the nation's economic stability. In 2009, health care spending in the United States was 2.5 times greater than the Organisation for Economic Co-operation and Development average (OECD, 2013)
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, approved for colorectal cancer treatment, was initially priced at $11,000 per month of treatment, more than twice as much as for the usual dose of a medicine with similar patient outcomes. Pushback from a cancer center prompted Sanofi to provide hospitals and clinicians with a 50 percent discount on the price of Zaltrap (Pollack, 2012)
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citizens will be required to have health insurance coverage or pay a penalty. To ensure that individuals are able to obtain the mandated coverage, the ACA provides subsidies for some individuals and creates market reforms to foster increased access to private and public coverage for others.
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. By extending dependent coverage to as many as 3 million young adults and expanding health insurance coverage through Medicaid expansions and the Health Insurance Marketplace, the ACA may improve access to cancer care for the estimated 68,400 adolescents and young adults ages 15 to 39 who are diagnosed with cancer each year (Bleyer et al., 2012; NCI, 2013b; Sommers et al., 2013)
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Historically, such practices have made it difficult, if not impossible, for many cancer survivors to gain meaningful health insurance coverage. Requiring insurers to accept all applicants, regardless of their preexisting condition, is a major improvement for ensuring patients' access to cancer care.
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2010a. Interim final rules for group health plans and health insurance issuers relating to coverage of preventive services under the Patient Protection and Affordable Care Act.
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While these efforts ultimately aim to reduce the cost of health care in this country, other provisions of the law focus more directly on cost-saving measures. For example, the ACA created the CMS Innovation Center to allow states and other stakeholders to test new ways to improve the health of their communities, with the ultimate goal of improving patient outcomes while reducing costs.
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CMS also funds Medicaid jointly with the states. It is the largest health insurance program and the dominant payer of long-term care in the United States.
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, such as electronic health records, plays an important role in advancing cancer care. Multiple organizations, including the Office of the National Coordinator for Health Information Technology, the National Cancer Institute, and CMS, participate in health IT activities that support the effective and meaningful use of such technologies.
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Medicaid is run by the states to provide health insurance coverage to individuals with lower incomes. FDA The regulatory agency that ensures the safety, efficacy, and security of drugs, biological products, and medical devices.
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HRSA coordinates the National Center for Health Workforce Analysis, which collects workforce data, develops tools for projecting workforce supply and demand, and evaluates workforce policies and programs. HRSA also administers the National Health Service Corps, which provides scholarships and loan repayment to primary care clinicians practicing in areas with workforce shortages.
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Atlanta, GA: American Cancer Society. ACSCAN (American Cancer Society Cancer Action Network)
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2012. Young adults, cancer, health insurance, socio economic status, and the Patient Protection and Affordable Care Act.
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2000. Burdens and benefits of adjuvant Cyclophosphamide, Methotrexate, and Fluorouracil and Tamoxifen for elderly patients with breast cancer: The International Breast Cancer Study Group Trial VII.
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Journal of Clinical Oncology 25:5275-5280. Elmer, G
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2000. What threshold for adjuvant therapy in older breast cancer patients?
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2005. Effect of creatinine clearance on patterns of toxicity in older patients receiving adjuvant chemotherapy for breast cancer.
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2006. A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemother apy.
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2006. Social networks, social support, and survival after breast cancer diagnosis.
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2005. Pretreatment quality of life and functional status assessment signifi cantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: A prognostic analysis of the multicenter Italian lung cancer in the elderly study.
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http://www.cancer.gov/aboutnci/overview/mission (accessed June 27, 2013)
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2013. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults.
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2004. Enrollment of elderly patients in clinical trials for cancer drug registration: A 7-year experience by the US Food and Drug Administration.
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Journal of Clinical Oncology 21(8)
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Package • Requires all health plans sold to individuals and small businesses to cover a minimum set of services, including chronic disease management • Each state selects one plan to serve as the benchmark plan in their state Health Professional • Human service grant program Opportunity Grants • Provides comprehensive health care training and employment-related public services (e.g., transportation) to low-income workers Health Resources and • Established a fund to expand the existing program Services Administration • Provides access to primary health care for vulnerable (HRSA)
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86 DELIVERING HIGH-QUALITY CANCER CARE Provision Description State Option to Provide • Optional amendment to state Medicaid programs Health Homes for Enrollees • Allows beneficiaries with chronic conditions to be with Chronic Conditions enrolled into a health home Tobacco Cessation Services • Requires Medicaid to cover, without cost sharing, for Pregnant Women with counseling and pharmacotherapy services for tobacco Medicaid cessation for pregnant women Understanding Health • Data collecting and reporting requirement Disparities • All federally funded health care or public health programs, activities, or surveys must collect and report standardized data on race, ethnicity, sex, primary language, and disability status • National Coordinator for Health Information Technology to develop national standards for management of the data collected Coordination and Organization of Care Community Health Teams to • Grant program Support the Patient-Centered • Supports states in establishing community health Medical Home (PCMH) teams that can staff PCMH Medication Management • Grant program Services in Treatment of • Aids clinicians in delivering medication management Chronic Disease services for the treatment of chronic diseases National Center for Health • New section of HRSA Workforce Analysis • Collects health workforce data and intelligence National Health Care • Commission of 15 members appointed by the Workforce Commission Comptroller General • Coordinates federal efforts to monitor and address challenges faced by the nation's health care workforce Patient Navigator System • Reauthorization of a patient navigator program • Connects patients with health care service coordinators to diagnose, treat, and manage chronic disease(s)
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, screening and mammography recommended by the USPSTF, immunizations recommended by the Advisory Committee on Immunization Practices, and preventive care and screenings for youth and women recommended by HRSA Education and Outreach • National public-private partnership campaign Campaign Regarding • Funded through the Prevention and Public Health Preventive Benefits Fund • Raises awareness of the importance of prevention • Educates public and health care clinicians about preventive health services recommended by the USPSTF and covered by exchange programs National Prevention Strategy • Product of the National Prevention, Health Promotion and Public Health Council • Comprehensive plan to improve the health of the nation through preventive efforts Prevention and Public Health • Fund within HHS Fund • Makes investments in prevention and public health programs continued
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88 DELIVERING HIGH-QUALITY CANCER CARE Provision Description Reimbursement and Incentives Advanced Payment ACO • Incentive program in the CMS Innovation Center Model • Encourages participation in the Shared Savings Program o Provides ACOs with a pre-payment of a portion of their future shared savings o This money is to be invested in infrastructure and staff for care coordination Community Care Transitions • Five-year program in the CMS Innovation Center Program • Tests models for improving care transitions from the hospital to other settings and avoiding unnecessary hospital readmissions CMS Innovation Center • A new center in CMS • Tests innovative payment and service delivery models intended to reduce program expenditures, while preserving or enhancing the quality of care • HHS Secretary has the authority to scale successful delivery models up to the national level Hospital Readmissions • CMS program Reduction Program • Reduces Medicare payment to hospitals with high readmissions for specific conditions • Excludes hospitals providing primarily rehabilitative, psychiatric, or long-term care; children's hospitals; critical access hospitals; and certain cancer and research centers Hospital Value-Based • Incentive program in CMS Purchasing (VBP) Program • Hospitals are reimbursed for inpatient acute care services based on the quality of the care they provide, not the quantity of services • Hospitals publicly report performance on a set of quality measures Independent Payment • Independent 15-member panel of appointed experts Advisory Board • Recommends cost-saving measures for Medicare should it exceed an established targeted growth rate Medicare Advantage • Reward program in CMS Quality Bonus Payment • Bonuses paid to Medicare Advantage plans that meet Demonstration certain standards Medicare's Shared Savings • Incentive program in the CMS Innovation Center Program • Encourages the formation of accountable care organizations (ACOs)
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Medicare Qualified Entities • CMS program Data Release Program • Makes Medicare claims data available to qualifed entities to measure health care provider and supplier performance National Quality Strategy • National quality improvement strategy • HHS Secretary will annually update the strategy and identify priorities to improve the delivery of health care services, patient outcomes, and population health Public Reporting of Provider • HHS strategic framework for publicly reporting Performance Information provider performance information • Performance information available on a website, tailored to different viewers' perspectives Quality Measure • Component of National Quality Strategy Development • Requires HHS Secretary to select an entity to convene stakeholders and provide input on the selection of quality measures • Provides grants to entities for further improving, updating, or expanding quality measures • HHS Secretary to develop and periodically update outcome measures for hospital providers and physicians, including at least o 10 measurements for acute and chronic diseases; and o 10 measurements for primary and preventive care
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90 DELIVERING HIGH-QUALITY CANCER CARE Provision Description Rapid Learning Health Care/Information Technology/Infrastructure for Research Patient-Centered Outcomes • Nonprofit corporation Research Institute (PCORI) • Assists patients, clinicians, policy makers, and purchasers in making informed health decisions by assessing o National clinical research priorities o New clinical evidence and gaps in evidence o Relevance of clinical evidence and economic impact
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