April 2017 Edition Vol.11, Issue 4

State of Cancer Care: Opportunities and Challenges

By Christina Bennett, MS

Delivery of cancer care is on the cusp of a profound transformation, while barriers to care persist according to The State of Cancer Care in America: 2017 report by the American Society of Clinical Oncology (ASCO).1

“The good news is we’ve gotten much better in treating and curing patients and making them live longer and live better,” said ASCO President Daniel F. Hayes, MD, FACP, FASCO.

According to the report, an estimated 2.1 million cancer deaths have been averted in the United States since the cancer mortality rate peaked in 1991. The number of survivors in America is an estimated 15.5 million, expected to reach 20.3 million by 2026, and 26.1 million by 2040. In addition, cancer incidence has declined by 0.9 percent annually over the past decade.

In a briefing on Capitol Hill, Dr. Hayes highlighted how immunotherapy has provided cures for diseases, such as melanoma and certain types of metastatic non–small-cell lung cancer that hardly had any treatments available, as well as advances in precision medicine coupled with some “really spectacular” advances in tissue diagnostics and liquid biopsies.

The FDA approved several cancer diagnostic tests last year, two of which were for liquid biopsies.

In addition, the 21st Century Cures Act was passed, providing $352 million in supplemental National Institutes of Health funding to support the Cancer Moonshot Initiative for fiscal year 2017.

On the horizon is the arrival of learning healthcare systems, such as ASCO’s CancerLinQ, which analyze the wealth of data from electronic health records (EHRs) and other sources to generate evidence that can be applied to the clinic and research.

“Rapid discoveries in tumor biology have led to increasingly complex and personalized care,” said Dr. Hayes, adding that the amount of data available “is almost impossible for any single individual to understand. We’re getting way too complex, and we believe CancerLinQ and other learning health systems can help clinicians in practice take advantage of the remarkable advances we’ve made.”

Challenges to Providing Care

Despite considerable progress in providing cancer care, the report outlines challenges that may impede momentum forward, such as limited access to cancer care, whether due to lack of insurance, affordability, or both.

An estimated 27 million Americans remain uninsured, and evidence shows that insurance status is tied to health outcomes. For example, uninsured and Medicaid-insured patients with melanoma were more likely to have advanced disease symptoms at diagnosis and less likely to receive treatment than non–Medicaid-insured patients.

According to the report, one-third of cancer survivors aged 18 to 64 in the United States acquired debt because of their treatment. Of those in debt, more than half owed $10,000 or more and 3 percent declared bankruptcy.

Also, the cost of premiums for insurance plans through the Affordable Care Act (ACA) exchanges has increased with each new enrollment period. The cost of the silver plans, the most common, jumped on average by 25 percent between 2016 and 2017.

“As the cost of cancer care, and cancer drugs in particular, continues to increase, insurers are shifting more and more of the financial burden to the patient,” said Melissa Dillmon, MD, chair-elect of ASCO’s State Affiliate Council. The result is that cancer patients are paying more for care than ever before, she said.

Oral therapies can have considerably higher co-pays than those of intravenous therapies, and to date, no federal law exists to protect patients from inconsistent cost-sharing. However, oral parity laws enforcing comparable coverage for oral and intravenous treatments are in effect in 42 states and Washington, DC.

As the number of cancer survivors increases in America, so does the demand for oncologists, and the report notes that keeping up with demand is a challenge—and is compounded by an aging workforce and lack of oncologists in rural areas.

Oncologists nearing retirement age make up 18.4 percent of the workforce whereas those younger than 40 make up 13.3 percent.

Urban areas have approximately five oncologists per 100,000 residents contrasted with rural areas having only one oncologist per 100,000 residents. The problem is most evident in Montana and Oklahoma, where a high proportion of their populations reside in rural areas yet no oncologists practice in these communities.

“ASCO is concerned about lack of access to providers in rural areas in light of the multiple visits and types of specialists that cancer care services require,” said Dr. Dillmon.

To address this workforce problem, Dr. Hayes offered a few possible solutions: encouraging medical students to become oncologists, partnering with primary care doctors, and incorporating more advanced practice practitioners into the delivery of care.

Rising expenses to run a practice was the most cited concern in the report and the burden is compounded by the ever-increasing administrative duties of physicians. Nearly half of a physician’s time is devoted to EHR documentation and desk work, whereas only about a quarter of their time is spent on patient care, notes the report.
“There definitely has been tremendous increase in the burden of paperwork that we have to do,” said Kashyap Patel, MD, oncologist at Carolina Blood and Cancer Center and part of the Board Executive Committee at Community Oncology Alliance.

Dr. Patel cited EHR documentation, preauthorization requirements, and the intermediary business entities, such as pharmacy benefit managers as contributors to this increase.

He explained that some of the reporting requirements help streamline the quality of care but some of them don’t and instead place “unnecessary pressure” on providers, “which takes away time from the patient.”

“This clearly threatens our ability of delivering the best possible care that we can under the circumstances,” said Dr. Patel.

The authors of the report encouraged Congress, the Administration, and payers and insurers to “streamline these requirements so that oncology professionals are able to focus time and resources on their patients.”

Transition to Value-Based Care

Substantial transformation of cancer care delivery from volume to value looms ahead as the healthcare system moves toward value-based care. The first dramatic change to shift this is the Medicare Access and CHIP Reauthorization Act (MACRA).

MACRA redefines how physicians are reimbursed when providing care to Medicare beneficiaries.

“We believe it will generate higher quality and better value care for patients instead of fee-for-service, but it will be a challenge to move into this,” said Dr. Hayes.

Within MACRA, physicians can choose from one of two payment pathways: Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). The belief is that most physicians will start in MIPS and eventually all physicians will be using APMs in their practices.

ASCO has proposed their own oncology-specific APM called Patient-Centered Oncology Payment (PCOP), but the Centers for Medicaid and Medicare Services (CMS) has not yet approved this payment model.

ASCO told OBR they hope to have PCOP ready for review late summer or early fall of this year, but the CMS Physician-Focused Payment Model Technical Advisory Committee will set the date of review.

Last year, CMS selected nearly 200 oncology practices to participate in the Oncology Care Model (OCM) as part of a demonstration project. OCM is an APM in which the full set of services used by patients receiving chemotherapy are supported by episode-based payments.

Practices who are participating in this demonstration project are required to meet several OCM requirements, including 24 hours a day, 7 days a week access to care, continuous quality improvement, and patient navigation throughout care.

Practice Perspective

Texas Oncology, a physician-led practice that treats about half of all cancer patients in Texas, was selected to participate in the demonstration project.

“I think most people were doing a good job taking care of their cancer patients before [OCM],” said Lalan Wilfong, MD, co-leader of the OCM initiative at Texas Oncology. “But there really wasn’t a systematic approach” to executing all the changes that the practice has now.

Some of these changes include proactively calling patients to check up on them and blocking off appointment slots for walk-ins. These changes aim to reduce trips to the emergency room and hospitalization—ultimately curbing costs and providing more value to patients. Also, communication has been a key change.

“We’ve really focused on better communication in our clinic,” Dr. Wilfong said. “Everyone speaks to each other about the patient.”

One of the challenges observed by Dr. Wilfong is that although “it’s the way we should be practicing, it really is a different mindset for patient care.”

For instance, he explained that providers must truly take the time to have conversations with patients about their diagnosis and their prognosis. Another is documentation requirements.

“There is a burden placed on practice management because of all the different requirements that we have to do,” said Dr. Wilfong. “We’re spending additional time doing tasks that we weren’t doing before.”

Dr. Patel, who belongs to a practice also participating in the OCM, said, “I may not agree with a lot of the reporting requirements, but I do feel we are heading in the right direction.”

Also, talking to patients about total cost of care, an OCM requirement, can be difficult.

“We can tell them pretty easily the cost they incur in our clinic,” said Dr. Wilfong. As far as relaying costs incurred outside of a practice’s office, such as hospitalization and emergency room visits, he said, “Obviously, that is a very difficult thing to do.”

Unpreparedness among Physicians

One concern in the report was that “many physicians are unaware of MACRA reforms and are unprepared to make changes to their practice to meet its requirements.” One survey reported half of 523 surveyed physicians had never heard of the law and 32 percent were familiar with the name, but not the requirements.

“I don’t think we were terribly surprised by the finding,” Dr. Hayes said regarding the lack of awareness among physicians. “On the other hand, our feeling is that oncologists are probably the most aware of what’s going on with MACRA.”

He cited the reason for this as being ASCO’s providing of “considerable resources to educate our members.”

Value Frameworks

In addition to MACRA, the ASCO report outlined oncology-specific value frameworks that have emerged to providing value-based care.

“The physician and patient can sit and have a logical and well-informed discussion instead of just opinions and perspectives,” Dr. Hayes said regarding the purpose of value frameworks.

Frameworks detailed in the report include ASCO’s Value Framework, Memorial Sloan Kettering Cancer Center’s tool DrugAbacus, and National Comprehensive Cancer Network’s Evidence Blocks.

However, limitations exist, and as the authors wrote, “value initiatives are relatively new and the oncology frameworks proposed in 2016 are largely conceptual.”

“Value is a much-used word with a very poor definition, especially in medicine,” said Dr. Hayes.

Defining value successfully is a limitation of the current frameworks, particularly because this definition can vary among payers, patients, and oncologists. Also, patient perspective is lacking from current frameworks and the frameworks rely heavily on data from clinical trials, which do not allow cross-trial comparisons. Cross-trial comparisons are essential to evaluating benefit and toxicity across several treatment regimens.

“The value framework is not ready to roll out yet to practices,” Dr. Hayes said, referring to ASCO’s framework. “We’re continuing to refine it and trying to make that ready, but at least it’s a step, in my opinion, in the right direction.”

Resources:

  1. American Society of Clinical Oncology. The State of Cancer Care in America, 2017: A Report by the American Society of Clinical Oncology. J Oncol Pract. 2017;13(4):e353-e394.

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