National Academies Press: OpenBook

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis (2013)

Chapter: 8 Accessible and Affordable Cancer Care

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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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8

Accessible and Affordable Cancer Care

The committee’s vision for a cancer care delivery system is one in which all people with cancer have access to high-quality, affordable cancer care. Underpinning this system are new payment models that reward cancer care teams for providing patient-centered, high-quality care and eliminating wasteful interventions. The committee’s conceptual framework (see Figure S-2) illustrates the concept of rewarding clinicians for high-quality care through quality measurement and new payment models that promote accessible, affordable, high-quality cancer care. The focus on improving access to cancer care is consistent with the Institute of Medicine’s (IOM’s) report Ensuring Quality Cancer Care, which recommended enhancing services for the un- and underinsured and conducting studies to assess the reasons why certain segments of the population do not receive appropriate cancer care (IOM and NRC, 1999). The focus on affordability is a major update in this report.

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). Many of the disparities are exacerbated by these individuals’ lack of access to cancer care. Social determinants of health1 that extend beyond the health care system, such as individuals’ education, economic opportunity, and neighborhood and

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1 Social determinants of health are defined by the World Health Organization as “the conditions in which people are born, grow, live, work, and age” (WHO, 2013).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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community factors, can also drive these disparities (see discussion in Chapter 2).

At the same time, the increased costs of cancer care are negatively impacting patients and their families (Bernard et al., 2011; Shankaran et al., 2012). People with cancer are at higher risk for bankruptcy than people without a cancer diagnosis (Ramsey et al., 2013). In addition, a survey found that more than a third of individuals reported that medical problems were the reason for bankruptcy, even though three out of four families studied had insurance at the onset of illness (Himmelstein et al., 2009). From a system perspective, health care costs, including the costs of cancer care, are on an unsustainable trajectory that could pose serious fiscal consequences for the United States. Drivers of increased cancer spending include the aging population and the associated increase in cancer diagnoses, as well as the diffusion of new innovations into practice that may or may not be supported by evidence of better patient outcomes. In addition, the current fee-for-service reimbursement system encourages a high volume of care, but fails to reward the provision of high-quality care.

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. The second half of the chapter addresses the affordability of cancer care, reviewing the current challenges to delivering affordable cancer care and strategies for improvement, including eliminating waste, encouraging high-quality cancer care through new payment models, and considering changes to benefit design. The committee derived much of the evidence base on access from the IOM’s previous work in this area (IOM, 1993, 2001, 2003, 2004, 2009a). Presentations and discussions from the National Cancer Policy Forum workshop Delivering Affordable Cancer Care in the 21st Century informed the committee’s deliberations on affordability (IOM, 2013a). The committee identifies two recommendations to address the pressing problems of access and affordability.

ACCESSIBLE CANCER CARE

Access to care, or “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 1993, p. 4), is an important aspect of high-quality cancer care (IOM and NRC, 1999). Patients’ health insurance status is a factor influencing an individual’s ability to access high-quality cancer care. Certain health system, patient, and clinician characteristics can also affect patients’ access to care and cancer care outcomes. This section discusses the impact of health insurance coverage on

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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patients’ access to care and, more generally, vulnerable and underserved populations’ access to care.

Improve Access Through Health Insurance Coverage

Health insurance coverage is a critical way to increase patients’ access to cancer care (C-Change, 2008; Goss et al., 2009; IOM, 1993, 2004, 2009a). Health insurance coverage can improve care for individuals by increasing their likelihood of receiving preventive care, obtaining early diagnoses of disease, undergoing timely and appropriate treatment, and taking needed medications. Studies of previously uninsured adults found that when individuals became eligible for Medicare they could better access physician services and hospital care, and their use of effective clinical preventive services increased (reviewed in IOM, 2009a).

The IOM has repeatedly recommended that the United States ensure that all people have health insurance coverage. Most recently, in America’s Uninsured Crisis: Consequences for Health and Health Care, the IOM recommended that “the President work with Congress and other public and private sector leaders on an urgent basis to achieve health insurance coverage for everyone” (IOM, 2009a, p. 114). That recommendation echoes the earlier report Insuring America’s Health: Principles and Recommendations (2004), 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).

A primary goal of the Patient Protection and Affordable Care Act (ACA) is to expand health insurance coverage.2 Passage of the ACA is expected to result in 25 million people gaining insurance coverage by 2023 through the individual mandate, the expansion of Medicaid, the creation of Health Insurance Marketplaces, and coverage of young adults on their parents’ insurance plans (see Chapter 2) (CBO, 2013). In addition, a number of ACA provisions will expand access to cancer care by ensuring that certain health insurance plans cover important benefits, such as preventive care, cancer screenings, and routine costs for clinical trials, and by preventing certain health plans from imposing a lifetime dollar limit on most benefits (see Annex 2-1 for a more detailed description of the ACA). For example, insurance plans being offered through the Health Insurance Marketplaces will be required to cover essential health benefits, although

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2 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Congress, 2nd Sess. (March 23, 2010).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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the federal government has given states flexibility in determining which health benefits to designate as “essential” (HealthCare.gov, 2013a). Medicare must also cover annual wellness visits without cost sharing and fully cover many services recommended by the U.S. Preventive Services Task Force (Koh and Sebelius, 2010). Moreover, the ACA filled in the Medicare Part D prescription drug coverage gap, often called the “donut hole” (Koh and Sebelius, 2010).

Much of the ACA has not yet been implemented and its full impact on access to cancer care is unknown. The Congressional Budget Office estimates that approximately 90 percent of the nonelderly population will be insured by 2022 (CBO, 2012a) and the ACA could reduce the underinsured population by 70 percent (Schoen et al., 2011).

A number of individuals, however, will likely remain uninsured or underinsured. Due to the Supreme Court ruling on the ACA, states may opt out of the Medicaid expansion provision of the law that increases the eligibility for Medicaid to people with incomes of up to 138 percent of the federal poverty level (FPL).3 As of June 2013, 23 states and the District of Columbia plan to expand their Medicaid programs, 6 states are undecided, and 21 are not expanding their Medicaid program at this time (KFF, 2013). Although individuals between 100-138 percent of the FPL will be eligible for federal subsidies for coverage through the state health insurance Marketplaces, individuals below 100 percent of the FPL are not eligible for these subsidies (Kenney et al., 2012; Price and Eibner, 2013). Taking into account the states that are not expanding Medicaid, estimates suggest that around 30 million individuals will remain uninsured (CBO, 2013; Nardin et al., 2013). The uneven expansion of Medicaid may perpetuate disparities in access based on state of residence. Many of the remaining uninsured will be working age individuals (around 60 percent will be age 18-44) (Nardin et al., 2013). In addition, underinsurance may persist, placing people at risk for unaffordable health care costs, financial stress, and the inability to access high-quality cancer care (Schoen et al., 2008, 2011).

The ACA includes a number of provisions to monitor the effect of the law’s implementation on access to care. 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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3National Federation of Independent Businesses v. Sebelius, 132 S. Ct. 2566 (June 28, 2012).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Improve Access for Vulnerable and Underserved Populations

Health insurance coverage does not ensure individuals high-quality care (IOM, 2009a; IOM and NRC, 1999). Even after the ACA is fully implemented, it is likely that many cancer patients will continue to experience problems accessing the care they need. 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) affordability of care (e.g., financial resources, cost of health care, childcare, transportation, and productivity reduction [absenteeism and presenteeism4], as well as loss of employment due to cancer); (2) health care delivery system attributes (e.g., geographic distribution of cancer care facilities, hours of availability for patient care, or strength of service coordination); (3) patient attributes (e.g., perceptions of cancer prevention and treatment, lack of information, health literacy, language, or cultural factors); and (4) clinician attributes (e.g., communication style, cultural and language competencies, and treatment knowledge/expertise) (IOM and NRC, 1999).

The IOM has made numerous recommendations to improve access and care for individuals who are vulnerable and underserved (IOM, 1993, 1999, 2001, 2003, 2004, 2009a; IOM and NRC, 1999). The IOM report Crossing the Quality Chasm: A New Health System for the 21st Century (2001) included equity—defined as “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status”—as a major domain of high-quality care (IOM, 2001, p. 6). In Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the IOM recommended a series of interventions designed to eliminate health care disparities that targeted legal, regulatory, and policy issues; health system issues; patient education and empowerment; cross-cultural education in health professions; data collection and monitoring; and research needs (IOM, 2003). Ensuring Quality Cancer Care recommended that the research community focus on under-

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4 Presenteeism is attending work while sick.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

standing why specific segments of the population (e.g., racial and ethnic minorities and older patients) often do not receive appropriate cancer care (IOM and NRC, 1999). The IOM report The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved (1999) 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.

The federal government has undertaken significant efforts to collect data on the nature and impact of disparities for vulnerable and underserved populations. For example, the U.S. Department of Health and Human Services’ (HHS) Healthy People 2020 (2013a) tracks health outcomes across a number of demographic factors, including race and ethnicity, gender, sexual identity and orientation, disability status or special health care needs, and geographic location. Healthy People 2020 aims to achieve health equity (defined as the attainment of the highest level of health for all people), eliminate disparities, and improve the health of all groups (HHS, 2010). The Agency for Healthcare Research and Quality (AHRQ) publishes a yearly, congressionally mandated national health care disparities report (AHRQ, 2012b). The most recent report includes more than 250 measures of disparities, including some cancer-specific measures, and found that access did not improve for most vulnerable and underserved populations from 2002 to 2008; of the 250 measures, 50 percent showed no improvement and 40 percent of measures were getting worse (AHRQ, 2012c). Similarly, the NCI’s Surveillance, Epidemiology, and End Results (SEER) cancer registry expanded to collect information on diverse populations and it routinely reports cancer statistics by race, ethnicity, age, gender, and geography (NCI, 2013j).

Although the pervasiveness of disparities among vulnerable and underserved populations in the United States has been well documented, less progress has been made in eradicating these disparities (Spinks et al., 2012; Wallerstein et al., 2011).

The ACA includes multiple provisions designed to improve patients’ access to care and reduce disparities for vulnerable and underserved populations. These include establishing the Community Health Center Fund and the Prevention and Public Health Fund; reauthorizing the Patient Navigator and Chronic Disease Prevention grants; and expanding funding for the National Health Service Corps (see Annex 2-1 for a description of these programs). The ACA has mandated that all federally funded health care or public health programs collect and report data on race, ethnicity, sex, primary language, and disability status. It also elevated the National Center on Minority Health and Health Disparities to the level of an institute within NIH, granting the center the authority to develop

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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and evaluate all health disparities research conducted and supported by NIH, and to coordinate NIH’s health disparities strategic plan and budget (IOM, 2012b; NIH Record, 2010).

Many public and private efforts are also under way to improve patients’ access to care and address disparities for vulnerable and underserved populations (see Annex 8-1). For example, HHS created an action plan to reduce health disparities by transforming health care; strengthening infrastructure and workforce; advancing health, safety, well-being, and innovation; and increasing efficiency, transparency, and accountability (HHS, 2011). This plan was designed to complement the efforts of the National Partnership for Action to End Health Disparities, which was established to “mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity” (NPA, 2011, p. 1). Annex 8-1 also describes a number of additional efforts that aim to reduce barriers in access to health care for vulnerable and underserved populations, such as the NCI and C-Change’s involvement in patient navigation.

The barriers impeding patients’ access to care are often specific to the communities in which the patients live, and thus, the solutions to address those barriers are most likely to emerge from the communities. Some of the most promising efforts to improve access to care for vulnerable and underserved populations involve federal initiatives that focus on supporting community interventions.

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). Major components of the plan focus on evaluating partnership models that engage communities, identifying and targeting disparate populations, and providing comprehensive, integrated care at the community level. Similarly, HHS’ Million Hearts® Initiative works to prevent heart disease and stroke by improving access and quality of care through cardiovascular disease prevention activities coordinated across the public and private sectors (HHS, 2013b). The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are co-leading the Million Hearts® Initiative, along with the American Heart Association, the YMCA, and many other community organizations, with the goal of preventing one million heart attacks and strokes by 2017. In July 2013, President Obama signed an executive order announcing the HIV Care Continuum Initiative to mobilize and coordinate federal efforts to prevent and treat HIV infection (White House, 2013a). Many of the activities of the initiative will involve federal-level support of community-level programs, including

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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capacity building among community health centers, health departments, community-based organizations, and health care organizations (White House, 2013b).

Several organizations discussed in Annex 8-1 are also focusing on community-specific interventions to improve access and reduce disparities. C-Change’s Geographic Intervention Project, for example, is developing a community-based process for addressing health care disparities that can be leveraged by other communities. Similarly, the CDC’s Racial and Ethnic Approaches to Community Health (REACH) program provides funding for communities to implement and evaluate community-based approaches to improve health (CDC, 2012). REACH is a part of the CDC’s Healthy Communities program, which provides tools that support community action and convenes action institutes to help community leaders make policy, system, and environmental changes that aim to prevent chronic disease (CDC, 2011a).

Given the promise of federal initiatives that support community interventions, the committee recommends that HHS develop a national strategy to reduce disparities in access to cancer care for vulnerable and underserved populations by leveraging existing efforts by public and private organizations. As part of this strategy, the committee recommends that HHS (1) support the development of innovative programs, (2) identify and disseminate effective community interventions, and (3) provide ongoing support to existing successful community interventions (Recommendation 9).

An important focus of the national plan should be the dissemination of successful community interventions that improve access to high-quality cancer care for vulnerable and underserved populations. HHS’ role in disseminating successful community interventions could help other communities identify potential strategies that could be evaluated for their unique local environment and population. HHS should also help ensure the sustainability of successful community interventions. The committee recognizes that ongoing support will require substantial resources. Savings derived from other changes to the cancer care delivery system recommended by the committee may offset some of these costs.

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). This section explores the perverse incentives in the cur

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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rent reimbursement system for cancer care and presents three strategies for achieving affordable cancer care, while maintaining or improving the quality of care:

•   eliminating waste in the cancer care system by engaging clinicians and payers;

•   incentivizing affordable, high-quality cancer care by realigning the reimbursement system to reward high-quality, affordable cancer care; and

•   designing insurance benefits that enable patients to take an active role in choosing affordable, high-quality cancer care that aligns with their needs, values, and preferences.

These strategies have the potential to make cancer care more affordable for patients by reducing the incentive for clinicians to provide more (or more expensive) care that does not improve patient outcomes and by lowering patients’ cost sharing for high-quality cancer care.

Given the challenges to defining value in cancer care (see Box 8-1), the committee purposefully chose to frame its discussion in terms of high-quality 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). For example, the IOM report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America concluded that fee-for-service reimbursement does not reward clinicians for the quality of care they provide, and encourages wasteful and ineffective care (IOM, 2012a).

In the cancer care setting, fee-for-service reimbursement incentivizes clinicians to provide patients with interventions, even if there is a lack of evidence to show that those interventions improve patient outcomes. It also incentivizes clinicians to prescribe more expensive chemotherapy and recommend more costly methods of delivering radiation therapy, surgery, or imaging, irrespective of the benefits to patients (IOM, 2013a). One survey found that oncologists derive three-quarters of their practice revenues from chemotherapy drug charges (Akscin et al., 2007).

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5 Fee-for-service reimbursement is a financing methodology in which clinicians are reimbursed for each individual procedure or patient encounter (IOM, 2006).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

BOX 8-1
Defining Value in Cancer Care

Defining value in health care is challenging. Many definitions and concepts of value have been suggested. The basic premise of value is that it represents the quality of care relative to the cost of care. Value is created in care when outcomes improve and costs are maintained or when costs are reduced and outcomes are not adversely impacted.

Many attempts have been made recently to describe value in cancer care (Feeley et al., 2010; IOM, 2009b; Ramsey and Schickedanz, 2010). A 2009 Institute of Medicine (IOM) workshop on value in cancer care outlined attributes and metrics of value. Based on this workshop, Ramsey and Schickedanz (2010) suggested that “an intervention in cancer care can be described as having value if patients, their families, physicians, and health insurers all agree that the benefits afforded by the intervention are sufficient to support the total sum of resources expended for its use” (p. 2).

Other groups within the IOM have also grappled with how to define value in health care. The Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Health Care defined health care value as equivalent to net benefit: “the amount by which overall health benefit and/or well-being produced by care exceeds (or falls short of) the costs of producing it” (IOM, 2013b, p. 11). The IOM Roundtable on Value & Science-Driven Health Care held a workshop on value in health care, but concluded that “no single consistent definition of value was identified by the participants” (IOM, 2009d, p. xv).

The U.S. Department of Veterans Affairs (VA) has used a value equation in its quality improvement efforts, which is expressed as a ratio of outputs to inputs. Inputs include the financial resources of the VA, while outputs include technical quality of care, access to services, patient functional status, patient satisfaction, and community health (Perlin et al., 2004).

The Affordable Care Act used the term “value” more than 200 times, yet never defined the term. The Agency for Healthcare Research and Quality (2010) refers to improving value by reducing unnecessary costs (waste) and increasing efficiency while maintaining or improving health care quality. The United Kingdom’s

Previous changes in the way oncologists were reimbursed for chemotherapy administration, such as the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act, have influenced which drugs oncologists prescribe (Jacobson et al., 2006, 2010) (see also Box 8-2). A substantial number of oncologists in fee-for-service practice have reported that their income increases from administering chemotherapy or hematopoietic growth factors (Malin et al., 2013). At the same time, other important aspects of cancer care are not well compensated, such as

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

National Institute for Clinical Excellence applies the concept that the value of treatment is based on scientific value judgments, including a clinical evaluation and an economic evaluation, and social value judgments, including considerations of efficiency and effectiveness (Rawlins, 2004; Rawlins and Culyer, 2004).

Porter and Teisberg have defined value in health care as the health outcomes per dollar expended (Porter and Teisberg, 2006). This definition is premised on achieving the best possible outcomes as efficiently as possible (Lee, 2010). It places the responsibility for health reform on clinicians and assumes that the purpose of the health care system is not to minimize costs, but to deliver value to patients—in other words, better health per dollar spent (Porter and Teisberg, 2007).

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):

1.   Set the goal as value for patients; not access, equity, volume, convenience, or cost containment.

2.   Quality improvement is the key driver of cost containment and value improvement, where quality equals health outcomes.

3.   Care delivery should be organized around medical conditions over the full cycle of care.

4.   Provider experience, scale, and learning at the medical condition level drive value improvement.

5.   Care must be integrated across facilities and geography, rather than duplicating services within stand-alone units.

6.   One must measure and report outcomes and costs for every provider for every medical condition.

7.   Reimbursement must be aligned with value, and, furthermore, innovation needs to be rewarded.

A crosscutting principle of a value-based delivery system is that there needs to be an information technology platform that enables all aspects of the system to function as efficiently as possible.

cognitive care6 provided by physicians and support services offered by nurses, psychologists, chaplains, or social workers in cancer care (IOM, 2009b; Smith and Hillner, 2011) (see also Chapter 3). The extent to which oncologists in fee-for-service practice have been using the profit margins on chemotherapy to finance other uncompensated care is unknown, al-

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6 Cognitive care refers to evaluation and management services, which entails time spent discussing, for example, prognosis and treatment options (Smith and Hillner, 2011).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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BOX 8-2
Medicare Prescription Drug, Improvement, and Modernization Act

Enacted in 2003, the Medicare Prescription Drug, Improvement, and Modernization Act, also known as the Medicare Modernization Act (MMA), made substantial changes to the way Medicare Part B drugs are reimbursed, and established the Medicare Part D prescription drug benefit (Part D), expanding patient access to oncology drugs.

Most physician-administered oncology drugs, and some of their oral equivalents, are reimbursed under the Medicare Part B benefit. Prior to implementation of the MMA, Medicare paid providers 95 percent of the average wholesale price (AWP) for Part B drugs. A number of studies from the U.S. Government Accountability Office and the Health and Human Services’ Office of the Inspector General showed that reimbursing for AWP greatly exceeded clinician costs for these drugs (reviewed in MedPAC, 2003). In order to reduce overpaying for Part B drugs, the MMA changed the reimbursement from AWP to average sales price (ASP) plus a 6 percent administration fee. The year the payment change went into effect, there was an 8 percent decrease in spending (MedPAC, 2011). However, some suggest spending has not decreased as much as anticipated, in part, because drug manufacturers responded by raising their unit prices (IOM, 2013a). From 2006 to 2009, Medicare spending for Part B drugs increased at an average rate of 2.3 percent per year.

The Medicare prescription drug benefit (Part D) improved patients’ access to cancer treatment by extending drug coverage to Medicare beneficiaries. In the

though Bach asserted that the incentives in cancer care have promoted a culture of buying and selling cancer drugs at the expense of other aspects of cancer care (Bach, 2007).

Similar pressures influence the types of radiation therapy that clinicians provide (IOM, 2013a). Clinicians who own radiation therapy equipment have an incentive to prescribe this treatment over other types of interventions because they are financially rewarded under fee-for-service reimbursement (Bekelman et al., 2013). In addition, clinicians have rapidly diffused many radiation therapy innovations into clinical practice because of high fee-for-service reimbursement. 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). From 2000 to 2008, clinicians’ use of IMRT compared to 3-D conformal radiotherapy in prostate cancer increased from 0.15 percent to 95.9 percent (Sheets et al., 2012). From 2006 to 2009, the

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

cancer setting, Part D provides coverage for non-physician-administered drugs, including self-injectables and oral formulations of drugs. Part D drug benefit plans are required to cover “all or substantially all” drugs in certain therapeutic classes, including cancer (Bach, 2009; Bach and McClellan, 2005; Bowman et al., 2006). Yet, because private insurers administer Part D, each plan determines formulary design, cost-sharing structure, and utilization management tools. For example, a plan may require prior authorization for brand-name cancer drugs but not generic ones, or choose not to cover some brand-name cancer medications at all (Bowman et al., 2006). The Centers for Medicare & Medicaid Services (CMS) monitors formularies to ensure that no one disease or condition is discriminated against (Bach and McClellan, 2005). Bowman and colleagues (2006) found that 75 percent of cancer drugs were included in Part D plans’ formularies, and that most of the excluded cancer drugs were brand-name versions in which generic versions were available. However, Part D does not cover drugs that are prescribed for off-label uses unless they are medically necessary.a The MMA also created a coverage gap in which beneficiaries had to pay out of pocket when their annual drug costs ranged from approximately $900 to $4,400. The Affordable Care Act narrowed, and will eliminate by 2020, the coverage gap known as the “donut hole”.

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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. A large proportion of oncology drugs are prescribed for off-label purposes (Conti et al., 2013; Soares, 2005).

a 42 USCS § 1395w-104(b)(3)(G)(i).

number of Medicare beneficiaries receiving proton beam therapy almost doubled (Jarosek et al., 2012). In an analysis of Medicare patients receiving radiation therapy for prostate cancer, median reimbursement for proton therapy was $32,428 compared to $18,575 for IMRT, despite no difference in side effects at 12 months post-treatment (Yu et al., 2013). The use of brachytherapy in breast cancer offers another example of rapid diffusion of new technology without established evidence of benefit from trials (Smith et al., 2011).

Clinicians have also rapidly deployed surgical innovations into practice. For example, the use of robot-assisted prostatectomies grew substantially from 2005 to 2008 (Barbash and Glied, 2010). In 2011, clinicians used the robotic da Vinci Surgical System to conduct as many as four out of five radical prostatectomies (NCI, 2011). One study found clinicians’ use of robotic surgery increased the costs of surgery by about 13 percent and estimated that replacing open surgery with robotic surgery in all procedures would add $2.5 billion annually to health care expenditures (Barbash and Glied, 2010). While the rate of reimbursement is the same for

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

robotic-assisted procedures and their non-robotic-assisted counterparts (e.g., robotic-assisted laparoscopic radical prostatectomy [LRP] and LRP without robotic assistance), the total hospitalization charges for robotic surgeries is higher than the same surgeries without the assistance of a robotic system (Bolenz et al., 2012). Hospitals that have purchased the robotic surgical system profit from increased utilization of this equipment.

Waste is another unintended consequence of fee-for-service reimbursement. The Best Care at Lower Cost report estimated that more than $750 billion of health care costs are wasteful (IOM, 2012a). This study categorized waste in U.S. health care spending as unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed opportunities for prevention, and fraud.

In cancer care, overuse is a persistent problem (Katz and Morrow, 2013a,b; Schnipper et al., 2012). One study found that almost one-quarter of Medicare patients who had negative colonoscopy findings underwent another screening less than 7 years later, a screening interval not supported by current guidelines (Goodwin et al., 2011). In addition, many patients with metastatic non-small-cell lung cancer receive a greater number of treatments or higher doses of palliative radiotherapy than is supported by current evidence (Chen et al., 2013). Futile chemotherapy near the end of life is another example of overuse. 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).

In addition, fee-for-service reimbursement does not facilitate cancer care coordination because clinicians act as separate entities and are typically reimbursed accordingly (MedPAC, 2012). Failures of care coordination and the fragmentation of health care have been highlighted as critical problems of the cancer care system (see Chapter 4) (IOM, 2011; IOM and NRC, 1999; Spinks et al., 2012). Poor coordination can lead to costly duplication of care and result in patient complications. Fee-for-service reimbursement is especially problematic for patients who have comorbidities that must be managed by both the cancer care team and other specialist care teams.

A number of laws and regulations limit CMS’ and private insurers’ ability to pay for cancer care in ways that reward clinicians for providing high-quality and affordable care (Bach, 2009; Neumann and Chambers, 2012). State laws, affecting around 74 percent of the U.S. population, require coverage of cancer treatments if their use is recognized in the drug compendia, peer-reviewed literature, or both (Bach, 2009). The information in the compendia, however, is of variable quality and is often not supported by adequate evidence (Abernethy et al., 2010). Similarly, Medicare

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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is required to cover any Part B drug used in a chemotherapy regimen as long as its use is for a medically accepted indication (Bach, 2009). For Part D drug plans, formularies are required to include essentially all drugs “where restricted access would have major or life threatening clinical consequences … such as drugs used in the treatment of cancer” (Bach, 2009, p. 630).

This complex legal and regulatory framework makes it difficult for payers to use comparative effectiveness research evaluating the effectiveness of cancer drugs in reimbursement decisions (Pearson, 2012). Thus, “pharmaceutical firms know that these very expensive new cancer drugs will not be denied coverage by Medicare on the grounds of cost, and so they have no incentive to price them to meet any cost-effectiveness standard” (Brock, 2010, p. 38). This issue is further compounded by CMS’ inability to negotiate prices with pharmaceutical firms, even though it is the largest purchaser of cancer drugs.

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). ASCO’s policy statement on the cost of cancer care states that physicians have “a societal responsibility to provide care that minimizes waste and is evidence based” (Meropol et al., 2009, p. 3871). The physician charter of the American Board of Internal Medicine (ABIM) Foundation also states that physicians are responsible for “scrupulous avoidance of superfluous tests and procedures” (ABIM, 2013b).

Several clinician-led efforts to improve the quality and affordability of cancer are already under way. Community oncology practices, in collaboration with payers, have been assessing new models of cancer care delivery and payment (Hoverman et al., 2011; IOM, 2013a; Neubauer et al., 2010; Newcomer, 2012; Sprandio, 2010). ASCO has called for physicians to play a leadership role in the development and testing of new payment reform models (see discussion below in the section on “Incentivizing High-Quality Cancer Care”) (ASCO, 2013).

The ABIM’s Choosing Wisely® initiative is an example of a clinician-led effort targeted at eliminating waste. This program is designed to help clinicians and patients engage in conversations to minimize overuse of tests and procedures and to provide clinicians with the support they need to help patients make informed and effective health care decisions (ABIM, 2013a). It includes an explicit goal of avoiding care that is “unnecessary or

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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whose harm may outweigh the benefits” (Schnipper et al., 2012, p. 1716). ASCO is participating in this initiative and has released a “Top Five” list of common, costly procedures in oncology that are not supported by evidence and that require careful consideration by patients and their clinicians before using (Schnipper et al., 2012) (see Box 8-3). More recently, ASCO identified additional interventions to include on its list, and the American Society for Radiation Oncology released its own “Top Five” list (Choosing Wisely, 2013; Schnipper et al., 2013). Similarly, the Commission on Cancer has also submitted a “Top Five” list to the ABIM. 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) issued a “Top Five” list of common, costly procedures in oncology that are not supported by evidence in 2012 (shown below). The development of this list was led by ASCO’s Cost of Cancer Care Task Force, a multidisciplinary group of oncologists, and selections were based on a comprehensive review of published studies and current guidelines from ASCO and other organizations. The final list also reflects input from more than 200 oncologists and patient advocates.

•   For patients with advanced solid-tumor cancers who are unlikely to benefit, do not provide unnecessary anticancer therapy, such as chemotherapy, but instead focus on symptom relief and palliative care.

•   Do not use positron emission tomography (PET), computed tomography (CT), and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

•   Do not use PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

•   For individuals who have completed curative breast cancer treatment and have no physical symptoms of cancer recurrence, routine blood tests for biomarkers and advanced imaging tests should not be used to screen for cancer recurrences.

•   Avoid administering colony stimulating factors to patients undergoing chemotherapy who have less than a 20 percent risk for febrile neutropenia.

SOURCE: ASCO, 2012.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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practices that are unnecessary or where the harm may outweigh the benefits. The Choosing Wisely® initiative is an important step toward eliminating waste in health care and in focusing the nation’s attention on solving this problem. However, the current effort is being led by individual professional societies in silos, even though their areas of practice may overlap. In order for this campaign to have a larger impact, it will be important for professional societies to coordinate with each other to identify wasteful practices that cross disciplines and professions. A more systematic, integrated approach to evaluate cancer care practices that are contributing to waste will help establish a consistent message, improve the acceptability of the identified list of wasteful care practices in the cancer community, and, hopefully, result in broader uptake among clinicians. This approach will also be more efficient and reduce duplication of efforts.

It will be important for professional societies to disseminate these findings to their members and the public, and payers should also leverage this work to ensure that their payment policies are consistent with the goal of eliminating waste. Thus, the committee recommends that CMS and other payers develop payment policies that reflect the evidence-based findings of the professional societies.

Incentivizing High-Quality Cancer Care

Previous IOM reports have called for payers to reorient their reimbursement policies to reward clinicians for providing high-quality care rather than volume. Best Care at Lower Cost recommended that payers structure payments to reward continuous learning and improvement, patient-centered care, and team-based care through outcome- and value-oriented reimbursement models (IOM, 2012a). Crossing the Quality Chasm called on federal agencies to work with payers, health care organizations, and clinicians to develop a “research agenda to identify, pilot test, and evaluate various options for better aligning current payment methods with quality improvement goals” (IOM, 2001, p. 182).

Many other organizations have also reached similar conclusions regarding the need for new payment models. For example, the National Commission on Physician Payment Reform recommended that fee-for-service payment be largely eliminated because of its “inherent inefficiencies and problematic financial incentives” (Report of the National Commission on Physician Payment Reform, 2013, p. 14). The Commission recommended testing new models of care that reward clinicians for providing high-quality and efficient care over a 5-year period and implementing them on a more widespread scale by the end of the decade. The Partnership for Sustainable Health Care, a collaboration of five organizations represent-

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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ing diverse stakeholders in health care,7 called for transformation of the current payment paradigm by transitioning away from fee-for-service reimbursement (Partnership for Sustainable Health Care, 2013). It also recommended the dissemination and implementation of alternative payment and delivery models that improve quality and efficiency over the next 5 years. 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).

Building on these previous reports, the committee recommends that CMS and other payers design and evaluate new payment models that incentivize the cancer care team to provide care that is based on the best available evidence and aligns with their patients’ needs, values, and preferences. This recommendation has the potential to facilitate many of the components of the committee’s conceptual framework, including incentivizing

•   effective patient-clinician communication and shared decision-making that supports patients and caregivers in making informed medical decisions consistent with their needs, values, and preferences, as well as advance care planning, the provision of palliative care and psychosocial support across the cancer continuum, and the timely referral to hospice care at the end of life (Chapter 3);

•   team-based cancer care that prioritizes patient-centered care and coordination with a patient’s primary care/geriatrics care team and other care teams, especially for patients with comorbidities (Chapter 4);

•   evidence-based cancer care that is concordant with clinical practice guidelines and consistent with patients’ needs, values, and preferences (Chapter 5);

•   clinician participation in the learning health care system and the national quality reporting program (Chapters 6 and 7); and

•   reduced use of interventions that do not improve patient outcomes and contribute to unsustainable health care costs (see discussion above in the section on Eliminating Waste in Cancer Care).

It is important that payers be thoughtful in implementing these new reimbursement models because changing financial incentives will lead

________________

7 The Partnership includes America’s Health Insurance Plans, Ascension Health, Families USA, the National Coalition on Health Care, and the Pacific Business Group on Health.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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to changes in oncology practice (Colla et al., 2012; Jacobson et al., 2006, 2010). The committee hopes that these changes will be beneficial, with the potential to achieve the aims of the committee’s conceptual framework. However, they could also be harmful, resulting in unintended adverse consequences, perverse incentives, and lack of improvements to patient care (Biller-Andorno and Lee, 2013; Flodgren et al., 2011; RAND, 2011). Poorly implemented payment models could reduce patients’ access to care if clinicians avoid high-risk or high-cost patients, or could lead to the underuse of evidence-based care in an effort to save resources (RAND, 2011).

It is important that payers’ implementation of new reimbursement models is embedded within the committee’s conceptual framework for improving the quality of cancer care because changing economic incentives is necessary, but insufficient, to improve the quality of cancer care (Biller-Andorno and Lee, 2013). The committee’s recommendation to create a more robust quality metrics reporting system (see Chapter 7) and the inclusion of performance metrics in many of the models discussed below will be critical to ensuring that payment reforms maintain or improve the quality of cancer care and do not result in unintended negative consequences. The committee also recommends that clinicians work with their professional societies to identify and disseminate cancer care practices that are unnecessary or where the harm may outweigh the benefits (see discussion above on eliminating waste) (ABIM, 2013b).

In addition, many of the committee’s recommendations aim to make it easier for clinicians to deliver high-quality cancer care: for example, through improved tools to guide shared decision making and capture it in care plans. A learning health care information technology system for cancer would include clinical decision support that facilitates the delivery of evidence-based cancer care (see Chapter 6). It would also improve care coordination in conjunction with care plans. Moreover, the components of the committee’s conceptual framework are interdependent. Thus, removing perverse payment incentives will also have the added benefit of facilitating implementation of the other requirements for a high-quality cancer care delivery system. 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). The CMS Innovation Center has the authority to expand these innovative models nationally if they demonstrate improvements in quality, reduce costs, or both. Although the models currently being tested are generally not disease specific, the lessons learned from these demonstra-

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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BOX 8-4
The CMS Innovation Center

The Affordable Care Act established the Center for Medicare & Medicaid Innovation (recently renamed the CMS Innovation Center) for testing new delivery system and payment models to improve the quality of care and reduce health care costs. The Secretary of Health and Human Services has the authority to expand the scope and duration of successful models nationwide through a rulemaking process (CMS, 2013a). Each model the CMS Innovation Center tests is evaluated based on the quality of care that clinicians provided when practicing under the parameters of the model (based on patient outcomes and patient-centeredness criteria), as well as changes in costs measured by the Rapid Cycle Evaluation Group (Shrank, 2013).

The CMS Innovation Center is currently testing seven categories of innovation models (CMS, 2013e):

1.   Accountable care organizations (ACOs)

2.   Bundled payments for care improvement

3.   Primary care transformation

4.   Initiatives focused on Medicaid and the Children’s Health Insurance Program population

5.   Initiatives focused on dually eligible Medicare-Medicaid enrollees

6.   Initiatives to speed adoption of best practices

7.   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. In addition, the second round of Health Care Innovation Awards specificially solicits proposals for new payment and delivery models for cancer care (CMS, 2013j).

A number of health care payers and oncology practices have also been experimenting with different payment models to improve the quality and reduce the cost of cancer care (Hoverman et al., 2011; Neubauer et al., 2010; Newcomer, 2012; Sprandio, 2010). Table 8-1 summarizes examples of innovative payment models that are currently being explored to realign financial incentives in health care (RAND, 2011). The sections below discuss the most promising examples for cancer care in more detail, including bundled payments, ACOs, oncology patient-centered medical homes (PCMHs), care pathways, coverage with evidence development, and value-based purchasing (VBP) and competitive bidding.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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TABLE 8-1 Examples of Payment Reform Models Relevant to Cancer Care

Payment Reform Models Brief Description
Global payment A single per-member, per-month payment is made for all services delivered to a patient, with payment adjustments based on measured performance and patient risk.
Accountable care organization (ACO) shared savings program Groups of clinicians and provider groups that voluntarily assume responsibility for the care of a population of patients (known as ACOs) share payer savings if they meet quality and cost performance benchmarks.
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.
Bundled payment A single “bundled” payment, which may be shared by multiple clinicians or provider groups in multiple care settings, is made for services delivered during an episode of care related to a patients’ medical condition or procedure.
Hospital-physician gainsharing Hospitals are permitted to provide payments to physicians that represent a share of savings resulting from collaborative efforts between the hospital and physicians to improve quality and efficiency.
Payment for coordination Payments are made to clinicians and provider groups furnishing care coordination services that integrate care among clinicians.
Physician pay-for-performance Physicians receive differential payments for meeting or missing performance benchmarks.
Payment for shared decision making Reimbursement is provided for shared decision-making services.

SOURCE: Adapted from RAND. 2011. Payment reform: Analysis of models and performance measurement implications. http://www.rand.org/pubs/technical_reports/TR841.html (accessed Novembe 1, 2013). © 2011 The RAND Corporation, Santa Monica, CA. Reprinted with permission.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Because the effectiveness of these payment and delivery system reforms is still being evaluated by a number of payers, the committee does not recommend a specific strategy going forward. However, the committee recommends that if evaluations of specific payment models demonstrate increased quality and affordability, CMS and other payers should rapidly transition from traditional fee-for-service reimbursements to new payment models. If one payer demonstrates that new payment models are successful, these models will likely be adopted by other payers.

This recommendation is consistent with the IOM study Variation in Health Care Spending: Target Decision Making, Not Geography, which recommended that CMS be given the flexibility to accelerate the transition from traditional Medicare to new payment models that demonstrate increased value (IOM, 2013b). The committee also echoes this study’s recognition that it is important that CMS monitor the impact of new payment models on patients’ access to care. The transition from pilot programs to broader adoption of new payment models will be challenging and require major investments in infrastructure and organizational changes. During this transition, it is critical that patients do not experience reduced access to cancer care.

Bundled Payments

Bundled payments (also called episode-based payments) reimburse care teams for discrete episodes of care and can involve multiple clinicians and care settings (RAND, 2011). They shift financial risk away from insurers and make clinicians more accountable for efficiently using resources. They can also promote better care coordination if a bundle covers multiple modalities in cancer care (e.g., surgery, chemotherapy, and radiation therapy).

There is some evidence that bundled payments reduce health care costs. In 2004, AHRQ undertook an evaluation of bundled payments and concluded that there is “evidence that bundled payment programs have been effective in cost containment without major effects on quality” (AHRQ, 2012a, p. vi). For example, the Medicare Participating Heart Bypass Center Demonstration, conducted in the 1990s, assessed the impact of bundled payments on hospital and physician payments for coronary artery bypass graft surgery. Researchers found that Medicare expenditures declined by about 10 percent in the demonstration program, compared to what Medicare would have spent in the absence of the program. Five hospitals experienced savings of 5 to 10 percent and two hospitals experienced savings of about 20 percent (CBO, 2012b; HCFA, 1998). In an evaluation of eight policy options to reduce health care spending, Hussey et al. (2009) concluded that bundled payments have the greatest potential.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Many efforts are under way to implement bundled payments. Arkansas is incorporating bundled payments in its Medicaid program (Emanuel, 2012). Also, the CMS Innovation Center is evaluating bundled payments through its Bundled Payments for Care Improvement Initiative (CMS, 2013c), which includes four distinct models of care that link payments for multiple services:

1.   Retrospective acute care hospital stay only

2.   Retrospective acute care hospital stay plus post-acute care

3.   Retrospective post-acute care only

4.   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). Bach and colleagues (2011) proposed creating an episode-based payment pilot in Medicare for treating metastatic non-small-cell lung cancer. There are a number of chemotherapy options with similar patient outcomes that the National Comprehensive Cancer Network (NCCN) recommends for this disease. In this proposed pilot, Medicare would set an episode-based payment at a price in between the highest- and lowest-cost treatment regimens, including the cost of chemotherapy drugs, supportive care drugs, and the cost of administering these drugs. This would provide clinicians with a financial incentive to choose the lower cost, equally effective treatment options for their patients. Over time, the episode-based payment would be recalibrated downward to save costs.

Bach and colleagues’ episode-based payment pilot could also be effective in treating other cancers where there are comparable treatment regimens at varying prices. It would not be applicable for cancers where it is unclear which treatments result in similar patient outcomes and comparative effectiveness data are unavailable, such as early-stage prostate cancer, for which there are a number of different treatment options, including radical prostatectomy, radiation therapy, and active surveillance (IOM, 2009c).

UnitedHealthcare has also initiated a bundled payment pilot for cancer care (Newcomer, 2012). In this pilot, UnitedHealthcare pays clinicians a set patient care fee regardless of which chemotherapy is prescribed, thus eliminating clinicians’ ability to profit from chemotherapy administration. The initial care fee was established by allowing the participating cancer care teams to select what they thought represented the clinically superior treatment for 19 discrete episodes of care among patients with breast, colon, and lung cancer. The participating cancer care teams agreed to an

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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85 percent treatment compliance rate. The patient care fee was calculated using the drug margin from the selected regimen plus a case management fee. UnitedHealthcare continues to pay the cost of chemotherapy; however, if a clinician switches from the selected treatment regimen to a more expensive one, UnitedHealthcare will not increase the patient care fee. It will only raise the patient care fee based on improved outcomes. If the total cost of care is reduced, UnitedHealthcare will share the savings with the cancer care team. Participating groups have also agreed to meet yearly to compare results for the 19 episodes of care. If the data (including measures of survival, hospitalizations for complications, and total costs of care) identify a best practice, UnitedHealthcare expects all groups to shift to that treatment.

Accountable Care Organizations

RAND (2011) describes ACOs as groups of clinicians or provider groups that assume responsibility for the care of a group of patients and share savings when they satisfy quality and cost performance benchmarks. There are more than 400 public and private ACOs in the United States, including more than 250 public ACOs that provide care for nearly 4 million Medicare beneficiaries (Muhlestein, 2013). 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 already 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). Cancer Clinics of Excellence, for example, is collaborating with Accretive Health to develop a clinician-led, shared savings model of care in oncology. This shared savings model prioritizes care coordination and appropriate end-of-life care, eliminating unnecessary interventions, and encouraging adherence to care pathways. It also invests heavily in health information technology (IOM, 2013a). Similarly, Florida’s largest health insurer, Florida Blue, is collaborating with Moffitt Cancer Center, Baptist Health South Florida, and Advanced Medical Specialties to form oncology ACOs (BCBS, 2012; Conway, 2012).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Oncology Patient-Centered Medical Homes

PCMHs typically refer to a model of primary care delivery in which participating practices receive additional payments for coordinating their patients’ care. The AHRQ definition of a PCMH includes five functions and attributes: patient-centeredness; comprehensive care (prevention wellness, as well as chronic and acute care); coordinated care; access to care; and a systems-based approach to quality and safety (AHRQ, 2011).

The National Committee for Quality Assurance’s PCMH program recognizes organizations that achieve its PCMH standards. The standards include (1) enhanced access and continuity of care (including afterhours access); (2) data collection to identify and manage patient populations; (3) management of care using evidence-based clinical practice guidelines; (4) assistance with self-care management; (5) the tracking and coordination of care; and (6) continuous quality improvement using performance and patient experience data (NCQA, 2011).

The CMS Innovation Center is evaluating outcomes for medical homes in primary care. In these pilots, clinicians who coordinate care and provide higher-quality care, including care that adheres to guidelines and avoids complications, such as emergency room visits, receive monthly care management fees to help defray the costs of transforming into a PCMH (CMS, 2013d). A number of specialty medical practices are also exploring the use of the PCMH model to improve their quality and coordination of care (NCQA, 2013a). The National Committee for Quality Assurance has developed a recognition program for specialty practices that are successful at achieving the aims of a PCMH (NCQA, 2013b).

One specialty area where clinicians are applying the PCMH model is in cancer care (Fox, 2013; McAneny, 2013; Sprandio, 2010, 2012). The CMS Innovation Center awarded the Community Oncology Medical Homes (COME HOME) project $19.8 million to evaluate a medical home model for Medicare and Medicaid beneficiaries and commercially insured patients with newly diagnosed or relapsed breast, lung, or colorectal cancer (CMS, 2012b). COME HOME includes seven community oncology practices in the United States. These practices will provide comprehensive cancer care in the outpatient setting, including patient education, team-based care, medication management, 24/7 practice access, and inpatient care coordination. COME HOME utilizes Triage Pathways, which provide scripted responses to patients who call with problems about their cancer care. These scripts aim to rapidly send a patient to the right site of service and reduce costly complications and emergency room visits (McAneny, 2013). In addition, the COME HOME project requires clinicians’ adherence to care pathways and measures their pathway concordance on a nearly real-time basis.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Similarly, Consultants in Medical Oncology and Hematology (CMOH) became the first oncology practice designated as a level III PCMH by the National Committee for Quality Assurance (Sprandio, 2010, 2012). CMOH reengineered its processes of care and focused on improving coordination and collaboration for all cancer care; streamlining and standardizing the process of patient evaluation; and prioritizing patient engagement and physician accountability (Sprandio, 2010). Like COME HOME, CMOH uses a phone triage system with nurses and symptom management algorithms to address clinical issues. 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). More research is needed to assess whether the outcomes of the CMOH model are generalizable to other oncology practices.

Care Pathways

The oncology community has also experimented with changes in practice that standardize treatment using evidence-based care pathways. These care pathways “provide an evidence-based algorithm to guide care management for a defined group of patients during a set period of time” (ASCO, 2013). Pathways take into account the evidence base as well as the total cost of care. For example, U.S. Oncology has developed Level I Pathways for 14 common cancers (U.S. Oncology, 2013). Its evaluation of the program found that treating patients according to the Level I Pathways was associated with lower costs and comparable outcomes for patients with non-small-cell lung cancer and colon cancer (Hoverman et al., 2011; Neubauer et al., 2010). NCCN is collaborating with McKesson Specialty Health (the U.S. Oncology Network is a part of McKesson) to develop “Value Pathways,” with the goal of creating a single source of information on best practices in cancer care. The pathways and supporting software will initially cover 19 tumor types. These products will provide clinical decision support that is integrated with clinician workflow and compatible with a number of electronic health record systems (Goldberg, 2012; Goldsmith, 2013). Kaiser Permanente has also developed care pathways within its decision support software, including care paths for cancer survivors. This program has reduced the variation in clinical practice, with 90 percent of clinicians adhering to protocols on the first round of cancer treatment (IOM, 2013a).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Coverage with Evidence Development

Many expensive tests and treatments are introduced into clinical practice without evidence of clinical superiority over existing interventions. Once payers agree to cover new interventions, the incentive for manufacturers to conduct additional research on the effectiveness of their product is greatly reduced (Emanuel et al., 2013). Coverage with evidence development (CED) is a policy tool in which payers agree to conditionally cover new medical technologies provided that manufacturers conduct additional research to support more informed coverage decisions (CMTP, 2013a).

CED enables Medicare and other payers to develop more evidence-based coverage policies and fosters the collection of clinical evidence for groups who are often underrepresented in clinical trials, including older beneficiaries and minorities (MedPAC, 2010). 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. 7).

Legal concerns, however, have hampered CMS’ use of CED (MedPAC, 2010). In addition, when CMS launched CED studies in the past, problems with study design, insufficient funding, and inadequate data collection systems impeded the collection of data to inform coverage policies (Tunis et al., 2011). CED has therefore largely been applied on a case-by-case basis (CMTP, 2013b).

CED has previously been used in cancer for fluorodeoxyglucosepositron emission tomography (PET) imaging and identification of bone metastases using PET (sodium-fluoride 18) (CMS, 2013f,g,h). The treatment of localized prostate cancer is an additional area where CED has been suggested (ASTRO, 2013; Emanuel and Pearson, 2012). CED could also be used to incentivize the device industries to participate in evidence generation comparable to the research invested by the pharmaceutical industry in new drugs (Emanuel and Pearson, 2012; IOM, 2013a).

With the goal of improving CED, CMS solicited public comment on the current CED policy and issued a draft guidance policy in 2012 that clarified CMS’ authority to use CED (CMS, 2012a; Neumann and Chambers, 2013). The draft guidance also stated that one of AHRQ’s roles is to support research that reflects priorities in Medicare, including CED (CMS, 2012a; Daniel et al., 2013).

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Value-Based Purchasing and Competitive Bidding Programs

VBP links payments to improved performance by clinicians and holds clinicians accountable for both the cost and the quality of care they provide; “it attempts to reduce inappropriate care and to identify and reward the best-performing [clinicians]” (HealthCare.gov, 2013b). Two VBP programs are relevant to cancer care: hospital VBP and the physician value-based payment modifier. Section 10326 of the ACA requires the Secretary of HHS to initiate VBP for cancer hospitals exempt from the prospective payment system (Albright et al., 2011). In addition, Section 3007 of the ACA mandates CMS to apply a value modifier under the Medicare Physician Fee Schedule (CMS, 2013i). This will adjust physician payments under Medicare Part B based on performance of quality and cost metrics. The first performance assessment period begins in 2013, and the program will begin influencing payment in 2015. The program will be expanded to all physicians by 2017 (VanLare and Conway, 2012; VanLare et al., 2012).

Competitive bidding may also be relevant to cancer care. The ACA requires Medicare to expand competitive bidding for durable medical equipment nationwide (Emanuel et al., 2012). A demonstration project, begun in 2011, found that competitive bidding lowered the prices of oxygen equipment by 41 percent, wheelchairs by 36 percent, hospital beds by 44 percent, and diabetic testing equipment by 72 percent, with no adverse effects on beneficiaries (Emanuel, 2013). A number of health policy leaders have called for this program to be expanded and to include medical devices, laboratory tests, radiologic diagnostic services, and all other commodities (Emanuel et al., 2012).

Designing Insurance Benefits That Promote Affordable Cancer Care

Well-designed insurance benefits could encourage patients to be involved in making cancer care affordable. Some patients may be discouraged from using potentially beneficial treatments because they are responsible for significant levels of cost sharing for their cancer care. For example, the 10 Part D prescription drug plans with the highest enrollment in 2012 had coinsurance rates of 23 to 50 percent (Purvis and Rucker, 2012). For oral cancer drugs approved from 2000 to 2011, the median Part D coinsurance rate was 33 percent, and all of these drugs were included in the plans’ highest cost-sharing tiers (Cohen et al., 2013). For physician-administered cancer drugs, there is currently no upper limit for the amount of Medicare Part B cost sharing (MedPAC, 2012), with beneficiaries (or their supplemental insurance plans) responsible for the 20 percent coinsurance. These high coinsurance rates, coupled with the high cost of cancer treatments, can mean that many patients pay several

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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hundreds of dollars per treatment cycle, adding up to thousands of dollars annually (Cohen et al., 2013).

The Medicare Payment Advisory Commission (MedPAC) estimated that 6 percent of Medicare beneficiaries had Part A and B cost-sharing liabilities of more than $5,000 in 2009 (MedPAC, 2012). A study found that of the 10 percent of patients who did not fill their oral cancer treatment prescription, cost sharing was a significant factor in that decision (Streeter et al., 2011). A pilot study of insured cancer patients found that 42 percent of participants reported a significant or catastrophic subjective financial burden from the cost of mediciation, with 20 percent of participants taking less than the prescribed amount of medication, and 24 percent avoiding filling their prescriptions altogether (Zafar et al., 2013).

In contrast, well-insured patients may not be sensitive to the cost of cancer care because they do not bear the full cost of treatment. Thus, they may utilize more care or more expensive care even if it is unlikely to improve their health outcomes. A study commissioned by MedPAC found that individuals with supplemental insurance spent 33 percent more on Medicare compared to individuals without supplemental coverage, after controlling for demographics, income, education, and health status (Hogan, 2009). Almost 90 percent of Medicare beneficiaries have supplemental insurance coverage, either through medigap, employer-sponsored retiree plans, or Medicaid (MedPAC, 2012).

In order to incentivize patients to be more cost conscious in making care decisions, some employers and insurers have created consumer-directed health plans and increased cost-sharing requirements, which place patients at greater risk for the cost of their care. One of the concerns about consumer-directed health plans, however, is that patients have trouble distinguishing between interventions that are likely to be beneficial from those that are wasteful (Bundorf, 2012). Consistent evidence demonstrates that when patients bear more financial risk for their health care, utilization of both necessary and unnecessary health care services declines (IOM, 2009b; Reed et al., 2009; Remler and Greene, 2009; Siu et al., 1986).

Value-based insurance design (VBID) may facilitate patients’ ability to be more cost conscious without disincentivizing highly beneficial care. The National Coalition on Health Care suggested that VBID will be a “health system game-changer” (NCHC, 2012). It is intended to encourage patients to choose beneficial treatments and forgo treatments with little or no benefit (Frank et al., 2012). In this design, high-quality cancer interventions would be available at low or no out-of-pocket costs to patients, and interventions that are of questionable benefit to patients would require more cost sharing (IOM, 2009b). For example, palliative care could require little or no cost sharing because, as discussed in Chapter 3, it has been

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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shown to increase survival time for patients, improve symptom management and quality of life, and reduce the cost of cancer care (Morrison et al., 2008; Temel et al., 2010). An important challenge for implementing VBID in cancer is determining which interventions are of the highest quality. This will require both an improved evidence base (see Chapter 5), a learning health care system (see Chapter 6), and expert judgment.

VBID gained national prominence when Pitney Bowes announced $1 million in savings from its VBID program. It lowered patients’ cost sharing for asthma and diabetes medications, leading to increased medication compliance and reduced complications for these conditions (Fuhrmans, 2004). Similarly, several evaluations of VBID programs that eliminated generic medicine copays and/or reduced copays for brand-name drugs found that VBID improved patients’ medication adherence (Farley et al., 2012; Frank et al., 2012; Maciejewski et al., 2010).

Thus far, VBID has been primarily applied to drug copays, but it may be relevant in other aspects of care. MedPAC recommended that Medicare be given secretarial authority to alter or eliminate patients’ cost-sharing requirements for high-quality services and increase cost sharing for ineffective, high-cost services (MedPAC, 2012). In addition, the ACA’s call for coverage of preventive services is also a form of VBID (NCHC, 2012). The potential for VBID to improve the quality and affordability of cancer care has not yet been evaluated.

SUMMARY AND RECOMMENDATIONS

The committee’s conceptual framework for a cancer care delivery system is one in which all people with cancer have access to high-quality, affordable cancer care. Several IOM reports have called on the U.S. 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. However, much of the ACA has not yet been implemented and its full impact on access to cancer care is unknown. Many individuals will likely remain uninsured or underinsured. There are also major disparities in cancer outcomes among individuals who are of lower socioeconomic status, are racial or ethnic minorities, or lack insurance coverage. Many of these disparities are exacerbated by these individuals’ lack of access to cancer care.

Recommendation 9: Accessible, Affordable Cancer Care

Goal: Reduce disparities in access to cancer care for vulnerable and underserved populations.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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To accomplish this, the U.S. Department of Health and Human Services should

•   Develop a national strategy that leverages existing efforts by public and private organizations.

•   Support the development of innovative programs.

•   Identify and disseminate effective community interventions.

•   Provide ongoing support to successful existing community interventions.

The affordability of cancer care is equally important as accessibility in a high-quality cancer delivery care system. The committee’s conceptual framework (see Figure S-2) illustrates the concept of using quality measurement and new payment models to reward the cancer care team for providing patient-centered, high-quality care and eliminating wasteful interventions. The current fee-for-service reimbursement system encourages a high volume of care, but it fails to reward the provision of high-quality care. This system is leading to higher cancer care costs, which are negatively impacting patients and their families. One survey found that more than one-third of personal bankruptcies in the United States are due to medical problems and that three out of four families studied had insurance at the onset of illness. From a system perspective, health care costs, including the costs of cancer care, are on an unsustainable trajectory and could pose serious fiscal consequences for the United States.

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). Clinicians are also undertaking efforts to discourage wasteful interventions, such as the Choosing Wisely Campaign.

Recommendation 10: Accessible, Affordable Cancer Care

Goal: Improve the affordability of cancer care by leveraging existing efforts to reform payment and eliminate waste.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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To accomplish this:

•   Professional societies should identify and publicly disseminate evidence-based information about cancer care practices that are unnecessary or where the harm may outweigh the benefits.

•   The Centers for Medicare & Medicaid Services and other payers should develop payment policies that reflect the evidence-based findings of the professional societies.

•   The Centers for Medicare & Medicaid Services and other payers should design and evaluate new payment models that incentivize the cancer care team to provide care that is based on the best available evidence and aligns with their patients’ needs, values, and preferences.

•   If evaluations of specific payment models demonstrate increased quality and affordability, the Centers for Medicare & Medicaid Services and other payers should rapidly transition from traditional fee-for-service reimbursements to new payment models.

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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×

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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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ANNEX 8-1 EXAMPLES OF ONGOING ACTIVITIES DESIGNED TO IMPROVE ACCESS TO CARE FOR VULNERABLE AND UNDERSERVED POPULATIONS

Activity Description
Department of Health and Human Services (HHS)
Action Plan to Reduce Racial and Ethnic Health Disparities The Action Plan outlines goals and actions HHS should take to reduce racial and ethnic health disparities, including promoting integrated approaches, evidence-based programs, and best practices.
National Stakeholder Strategy for Achieving Health Equity The strategy outlines a comprehensive, community-based approach for achieving health equity. It provides a common set of goals and action steps that local public and private entities and collaborations may adopt to address racial and ethnic disparities within their communities.
Agency for Healthcare Research and Quality (AHRQ)
National Healthcare Disparities Report The yearly report tracks national trends in health care disparities. In cancer care, it focuses solely on colorectal and breast cancer in alternating years. The most recent report found that health care quality and access were suboptimal, especially for racial and ethnic minorities and lower income groups. There were disparities with respect to cancer screening, stage of diagnosis, treatment, and death rates among these groups.
Centers for Disease Control and Prevention (CDC)
Cancer Prevention and Control Research Network (CPCRN) CPCRN is a network of 10 academic, public health, and community partners that span multiple disciplines and geographic regions, and work together to conduct community-based participatory cancer research. 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 Control Program (NCCCP) NCCCP provides financial and infrastructural support to all 50 states, multiple tribes, and the U.S. Associated Pacific Islands and territories to assist in the development and implementation of comprehensive cancer control plans.
Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Activity Description
National Program of Cancer Registries (NPCR) NPCR compiles data from local cancer registries within each state. CDC uses this data to identify populations with disparities in cancer care. It also assists states in developing and implementing comprehensive cancer control programs designed to alleviate the disparities in these populations.
Racial and Ethnic Approaches to Community Health (REACH) REACH is a national grant program. It provides 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.
National Cancer Institute (NCI)
Cancer Disparities Research Partnership (CDRP) Program CDRP was developed by the Radiation Research Program to strengthen the NCI’s focus on cancer disparities. The CDRP supports institutions conducting radiation oncology clinical trials focused on medically underserved, low-income, and racial and ethnic minority populations by assisting with the planning, development, and conduct of the trials. The program also assists with the development of partnerships between institutions that are not actively involved in NCI-sponsored research and those that are. These partnerships serve to strengthen cancer disparities research and reduce the cancer disparities burden felt by particular populations.
Center to Reduce Cancer Health Disparities (CRCHD) The America Recovery and Reinvestment Act of 2009 awarded CRCHD $20 million. It distributed these funds to programs designed to preserve and create jobs, and promote greater scientific impact of research in underserved communities most affected by the recession. In addition, it provided supplemental funds to many of the flagship programs discussed below.
Centers for Population Health and Health Disparities The Centers fund research assessing the relationship between the environment, behavior, biology, and health outcomes. The Centers uses a community-based participatory research approach to develop a network of research teams to evaluate the multidimensional nature behind health disparities in cancer.
Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Activity Description
Community Cancer Centers Program The NCI has partnered with 21 community hospital-based cancer centers to create this program. Among the partnership’s areas of focus are researching ways to reduce health disparities in cancer, increasing participation in clinical trials, improving the quality of cancer care, enhancing cancer survivorship, expanding use of electronic health records, and promoting collection of biospecimens to support genomic research.
Community Networks Program This program awarded $95 million in 5-year grants to 25 institutions to establish a network of community-based participatory education, training, and research programs among racial and ethnic minorities and other underserved populations.
Comprehensive Partnerships to Reduce Cancer Health Disparities This program established a network of institutions and NCI Cancer Centers that serve racial, ethnic, and underserved communities. The goal of the program is to train scientists from diverse backgrounds in cancer research and in delivering cancer care to racially and ethnically diverse communities.
Diversity Training Programs The NCI developed diversity training programs through funding from CRCHD to engage underrepresented investigators in cancer research. The programs provide minorities from high school through the junior investigator level with a continuum of competitive funding opportunities. Programs include, for example, the Continuing Umbrella of Research Experiences and Partnerships to Advance Cancer Health Equity.
Minority-Based Community Clinical Oncology Programs (MB-CCOP) MB-CCOP is the component of the Community Clinical Oncology Network that is primarily responsible for engaging underserved populations and addressing health disparities in cancer through clinical trials. It has increased access to clinical trials in local communities; recruited many minority participants to clinical trials; and improved researchers’ understanding of how new agents, trial designs, and technologies are disseminated and utilized among minority populations.
Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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Activity Description
National Cancer Institute Community Oncology Research Program (NCORP) This program includes a research agenda to address cancer disparities. Goals of the research agenda include promoting participation of underserved populations in clinical trials and cancer care delivery research, as well as incorporating specific disparities research questions into clinical trials and cancer care delivery research. It prioritizes research that focuses on the potential drivers of cancer disparities, including health care system factors, health-related quality of life, social determinants, environmental and physical determinants, biological factors, behavioral factors, protective and/or resiliency factors, comorbidities, and biospecimen education and collection.
Patient Navigation Research Program This program supports the development and evaluation of innovative patient navigation interventions designed to reduce or eliminate health disparities in cancer. Examples of interventions that this program have funded include programs aimed at reducing time between abnormal test results and diagnosis, and improving the quality of cancer care delivery services for cancer patients.
American Cancer Society (ACS)a
Health Insurance Assistance Service A free resource that connects cancer patients with health insurance specialists who handle inquiries about health insurance coverage and state programs.
National Cancer Information Center This program provides patients with high-quality information on treatment options, cancer care facilities, community-based programs, clinical trials, and health insurance coverage. Trained oncology nurses answer patients’ more complex questions. An interpreter services helps address patients’ questions in 160 languages.
Patient Navigator Program This program hires and trains patient navigators to provide cancer patients and their families with free, one-on-one assistance and support throughout their cancer care, such as helping with the coordination of travel, referring to health care clinicians, providing assistance with psychosocial needs, identifying childcare resources, and recommending sources of financial assistance. Patient navigators are in 122 sites nationwide, with a concentration in public hospitals.
Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×
Activity Description
Transportation Programs The Road to Recovery Program provides a network of volunteer drivers who provide low-income cancer patients with transportation to and from their treatment. ACS also provides low-income cancer patients with other forms of financial assistance for transportation to and from treatment, including gas cards and tax vouchers.
Hope Lodge and Guest Room Program Provides cancer patients and their caregivers with a free place to stay or a low cost hotel room when they must travel for treatment. Currently, there are 31 Hope Lodge locations throughout the United States. Accommodations and eligibility requirements vary by location.
American Society of Clinical Oncology (ASCO)b
Disparities Research ASCO is working with key stakeholders in the cancer community to delineate where future research efforts in cancer disparities should be focused, both in terms of methodology and specific interventions. The resulting work will be developed into a monograph, or series of papers, identifying top research needs, especially in areas of research that have traditionally been underfunded.
Education ASCO regularly offers educational sessions at its annual meeting designed to help clinicians understand disparities in cancer care. It also offers an expanding array of educational content for providers on ASCO University, as well as resources for patients on Cancer.Net.
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. In addition, ASCO is developing a policy statement that will make recommendations for ensuring that Medicaid patients have access to high-quality cancer care.
Quality Improvement ASCO’s Quality Oncology Practice Initiative (QOPI) includes a focus on health equity by capturing practice-level information on race/ethnicity, socioeconomic/insurance status, and cultural competency. In addition, ASCO is seeking to assist practices that serve vulnerable and underserved patients with participating in QOPI.
Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
×
Activity Description
Workforce Diversity ASCO has developed and implemented two efforts to diversify the workforce caring for individuals with cancer. The Diversity in Oncology Initiative is an awards program designed to facilitate the recruitment and retention of individuals from populations underrepresented in medicine into careers in oncology. The awards provide individuals the opportunity to participate in an 8- to 10-week clinical or clinical research oncology rotation; pay for individuals to travel to and attend ASCO’s Annual Meeting; and repay student loans in exchange for 2 years of service in a medically underserved area. The Diversity Mentoring Program provides physicians who are early in their training and from populations underrepresented in medicine with an oncology mentor. It is designed to encourage these individuals to pursue a career in oncology.
C-Changec
Geographic Intervention Project C-Change is partnering with local and national organizations to intervene in communities disproportionately affected by four major preventable cancers (breast, cervical, colorectal, and lung). 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. The goal of this program is to develop a community-based process of addressing health disparities that is transferable to other communities.
Messaging Project C-Change worked with a communications firm to develop and test audience-specific messages and associated messaging tools on health disparities in cancer. This project is intended to ensure that C-Change and its membership organizations’ communications about health disparities in cancer resonate with the public and policy makers. The overarching goal is to heighten the public’s concern about health disparities in cancer care.

a Personal communication, Angelina Esparza, American Cancer Society, May 6, 2013.

b Personal communication, Dana Wollins, American Society of Clinical Oncology, March 21, 2013.

c Personal communication, Tasha Tilghman-Bryant, C-Change, March 21, 2013.

SOURCES: ACS, 2013a,b,c; AHRQ, 2013; C-Change, 2013; CDC, 2011b, 2012; CPCRN, 2013; Goss et al., 2009; HHS, 2011; McCaskill-Stevens and Clauser, 2012; Moy et al., 2011; NCI, 2013a,b,c,d,e,f,g,h,i; NPA, 2011.

Suggested Citation:"8 Accessible and Affordable Cancer Care." Institute of Medicine. 2013. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press. doi: 10.17226/18359.
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In the United States, approximately 14 million people have had cancer and more than 1.6 million new cases are diagnosed each year. However, more than a decade after the Institute of Medicine (IOM) first studied the quality of cancer care, the barriers to achieving excellent care for all cancer patients remain daunting. Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence. The cost of cancer care also is rising faster than many sectors of medicine--having increased to $125 billion in 2010 from $72 billion in 2004--and is projected to reach $173 billion by 2020. Rising costs are making cancer care less affordable for patients and their families and are creating disparities in patients' access to high-quality cancer care. There also are growing shortages of health professionals skilled in providing cancer care, and the number of adults age 65 and older--the group most susceptible to cancer--is expected to double by 2030, contributing to a 45 percent increase in the number of people developing cancer. The current care delivery system is poorly prepared to address the care needs of this population, which are complex due to altered physiology, functional and cognitive impairment, multiple coexisting diseases, increased side effects from treatment, and greater need for social support.

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis presents a conceptual framework for improving the quality of cancer care. This study proposes improvements to six interconnected components of care: (1) engaged patients; (2) an adequately staffed, trained, and coordinated workforce; (3) evidence-based care; (4) learning health care information technology (IT); (5) translation of evidence into clinical practice, quality measurement and performance improvement; and (6) accessible and affordable care. This report recommends changes across the board in these areas to improve the quality of care.

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis provides information for cancer care teams, patients and their families, researchers, quality metrics developers, and payers, as well as HHS, other federal agencies, and industry to reevaluate their current roles and responsibilities in cancer care and work together to develop a higher quality care delivery system. By working toward this shared goal, the cancer care community can improve the quality of life and outcomes for people facing a cancer diagnosis.

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