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‘We can do better’: ASCO report outlines persistent health care disparities, need for funding
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Over the next 10 years, the number of cancer survivors in the United States is expected to grow from 15.5 million to 20.3 million, according to ASCO’s State of Cancer Care in America: 2017 report released today.
To care for that burgeoning population, ASCO president Daniel F. Hayes, MD, FACP, FASCO, is calling on Congress to increase funding for cancer care and research and reject President Donald J. Trump’s proposed 20% cut in funding to the NIH.
“We now have a 20% cure rate for metastatic melanoma,” Hayes said during a press briefing on Capitol Hill. “I never in my life thought I would ever say we could cure someone with metastatic melanoma. This is [really] exciting. However, 80% of those patients are still dying, and we need to do better.
“We can do better, but not if it’s not funded,” Hayes added. “Every one of us will either have cancer or have a loved one or family member with cancer, and if you want us to keep treating people the way we are in 2017, give us a 20% NIH cut. But if you want us to keep making advances, we have to have the funding to make the advances.”
Health care coverage, accessibility
ASCO’s annual report, published in Journal of Oncology Practice, outlines new approaches for cancer diagnosis and treatment, improved data sharing to drive innovation and an increased focus on value-based health care.
However, access and affordability remain obstacles to high-value, high-quality cancer care.
An estimated 20 million Americans gained insurance in 2016 under the Affordable Care Act (ACA), which reduced the number of uninsured Americans to 27 million, or 8.6% of the population. However, those who elected the popular Silver Plan under the ACA saw their premiums increase by 25% from 2016 to 2017.
“Patients come into our offices daily, fearful that they may not have the cancer care they need and deserve because of cost issues and because of insurance issues they’re facing today,” Robin Zon, MD, FACP, oncologist at Michiana Hematology Oncology PC in Mishawaka, Indiana, and ASCO chair-elect of its government relations committee, said during the press briefing.
Congress should preserve protected access to the current ban on pre-existing condition limitations, prohibition of lifetime coverage caps and maintenance of guaranteed renewability, as well as address ongoing disparities in Medicaid by modifying requirements to include clinical trials, Zon said.
According to a study cited in the ASCO report, one in three working-age cancer survivors incurred debt as a result of treatment costs and, of those, 55% owed $10,000 or more and 3% filed for bankruptcy. These data highlight the fact that, for many patients — even those with health insurance — a cancer diagnosis can be financially catastrophic, according to the report.
“Financial strain as a side effect of cancer treatment can manifest as increased emotional and physical distress, which can actually affect a patient’s chances of survival,” Melissa Dillmon, MD, a hematologist/oncologist at Harbin Clinic Cancer Center in Rome, Georgia, and a member of ASCO’s government relations committee, said during the briefing. “As the cost of cancer care and cancer drugs, in particular, continue to increase, insurers are shifting more and more of the financial burden of cancer care to the patient and, as a result, cancer patients are paying more for their care than ever before.”
Medicare beneficiaries, for example, averaged more than $8,000 in annual out-of-pocket costs following a cancer diagnosis in 2016, which amounts to about a quarter of their income.
“Patients covered by Medicare often face rising out-of-pocket costs in their coverage, which can be especially harmful for a population that’s particularly susceptible to cancer,” Dillmon said.
Forty-two states have enacted oral medicine parity laws, and a similar bill has been introduced at the federal level. Still, copays for oral cancer therapies can be significantly higher than IV treatments often covered under a physician visit fee. For example, one young colon cancer patient had concerns over the cost of a generic colon cancer therapy, which rose from $200 in December to $500 in March, Dillmon said.
Health disparities, practice burdens
ASCO’s report also showed that substantial health disparities continue to persist among Americans of different race, ethnicity, socioeconomic status and geographic location.
For example, American black men with prostate cancer are more likely to experience longer wait times between diagnosis and treatment, more side effects from treatment and higher costs of care than American white men. Among Asian and Hispanic women, rates of breast and cervical cancer screening varied by insurance status and how long they were citizens of the United States.
Further, the hematology/oncology workforce is dwindling and unevenly distributed across the United States, with one oncologist per 100,000 rural residents compared with five oncologists per 100,000 urban residents. One quarter of all hematologists and oncologists in the United States practice in three states: California, New York and Texas, with Nevada, Idaho and Hawaii having the lowest number of oncologists per capita.
The report also notes that of the 12,100 practicing hematology/oncology professionals in the United States, 18% are aged 64 years or older, whereas 13% are younger than 40 years.
Oncology practices are also facing increased burdens, with more than half reporting that higher administrative and overhead costs have placed additional time constraints on their day-to-day operations, especially those of physician-owned practices.
In 2016, practices from common medical specialties spent a total of $15.4 billion and an average of 785 hours per physician to meet reporting requirements. One recent survey by ASCO revealed that a majority of practices identified increasing facility expenses as one of their top three concerns, followed by drug pricing and implementation of electronic health records (EHRs).
“In fact, one recent study of 16 practices found that physicians spend only 27% of their time with their patients, while 50% of their time is spent on EHR documentation and deskwork,” Dillmon said. “I believe those numbers are true.”
Cancer research advances
Despite these challenges, recent investments in biomedical research have led to major advances in precision medicine and immunotherapy.
There are now more than 200 cancer-fighting agents approved by the FDA. In 2016, the FDA approved 16 new and expanded-use cancer therapies, along with two cancer diagnostic tests — a liquid biopsy test for lung cancer mutations and a next-generation sequencing test to identify patients with advanced ovarian cancer.
“These two tests really advanced the concept of precision medicine into oncology and helps us understand which patients are most likely to benefit from specific therapy so we can get the right treatment to the right patient at the right time and at the right dose and schedule,” Hayes said.
For example, Zon cited an 84-year-old Medicare beneficiary diagnosed in 2003 at the age of 70 years with non–small cell lung cancer, which at that time had an average survival of 6 to 12 months. The woman harbored a specific biomarker that allowed her to receive a new oral therapy that put her in remission for 13 years before relapsing. At the time of her relapse last year, a new immunotherapy had just been approved for second-line therapy, and within 1 month, she was back to living a normal.
“We’re seeing this every day, and we don’t want our tomorrows stolen from our patients because there’s not ongoing research funding to allow those advances,” Zon said.
The ASCO report estimated that 2.1 million cancer deaths have been averted since 1991 because of these advances. However, by 2020, cancer is expected to surpass cardiovascular disease as the leading cause of death in the United States.
The national cancer moonshot initiative and the NIH precision medicine initiative offer additional promise in ASCO’s fight against cancer, Hayes said.
“We hope this will continue on the trajectory despite current proposals to the contrary,” he said. “We’ve seen flat funding of the NIH for 10 years until 2016, when we were pleased to have a small increase. Inflation went up during that time, and we’ve seen a wedge come between what we need and what we have. We need to catch up and we need to keep up.”
Zon concurred, adding that the moonshot initiative should “supplement, not supplant, funding for the NIH and the NCI.”
Moving forward
The past year marked significant steps toward value-based care delivery, spurred by CMS’ implementation of the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. The implementation of innovative payment models has paved the way toward value-based reimbursement, with 43% of physicians receiving some portion of their reimbursement under value-based systems and 58% of oncology practices using clinical pathways with a goal to improve quality and reduce cost.
“The ultimate goal [of MACRA] is to move public and private payers away from fee for service to payments based on the delivery of high-quality and high-value health care, which ASCO supports,” Hayes said.
Further, CancerLinQ — designed to use patient information to improve cancer care delivery and outcomes — now services 80 practices representing more than 2,000 physicians and more than 2 million patient records, allowing practitioners to stay current with the evidence necessary to deliver high-quality care.
The report also set forth recommendations in the following areas to strengthen the current system and ensure patient access to high-quality cancer care:
- Health insurance: All people with cancer should have health insurance that ensures access to high-quality cancer care delivered by a cancer specialist and provides the full range of services needed by patients in a timely manner;
- Federal funding of the NCI and FDA: To ensure the ongoing development and delivery of promising new treatments for patients with cancer, the federal government should provide adequate funding and infrastructure support for cancer research, continue funding the cancer moonshot initiative, and provide adequate resources to the FDA to review and approve the safety and efficacy of cancer therapies and diagnostics efficiently and quickly;
- Payment reform: As the nation moves from a volume-based to value-based health care reimbursement system, public and private payers should work with oncology providers and patients to develop new payment models that support patient-centered cancer care across care delivery settings. Further, CMS should support testing of multiple models in oncology, including ASCO’s Patient-Centered Oncology Payment model, as potential advanced alternative payment models for oncology care;
- EHR interoperability: To reach the full potential of cancer-specific rapid-learning health systems and accelerate the pace of cancer research progress, the Trump Administration should speed implementation of 21st Century Cures Act provisions to promote the interoperability of EHRs and prevent information blocking; and
- Administrative burden: As regulatory changes have significantly increased the administrative burdens health care providers face, policymakers and payers should streamline and standardize documentation and reporting requirements so that oncology professionals are able to focus adequate time and resources on their patients. – by Chuck Gormley