Commentary: Why did it take so long?
Medicare recently started to pay for patient navigation.
CMS has recognized the importance of patient navigation to improve health outcomes.
Why did this take so long despite decades of advocacy from patient advocates and caretakers across our country? Probably a failure on the part of the “hierarchy” to understand the complexity of cancer care and the disparities in screening and treatment over the decades.
Helping all individuals
Patient navigation is designed to promote access to timely diagnosis and treatment of cancer and other chronic diseases by targeting and eliminating barriers to care for all individuals.
“All individuals” is the key.
The concept of patient navigation was the result of findings of American Cancer Society national hearings on cancer and the poor.
Hearings took place in 1989 in seven American cities, with the majority of testimony given by low-income Americans of all races and ethnic groups who had been diagnosed with cancer.
Later that year, based on these hearings, the American Cancer Society issued a report to the nation on cancer and the poor.
Based upon the society’s findings, Harold P. Freeman, MD, conceived and started the nation’s first patient navigation program at Harlem Hospital Center in New York in 1990.
Freeman’s program focused on the effort to reduce cancer mortality by eliminating barriers to timely care during the period between identification of a suspected finding to resolution by additional diagnosis and treatment.
The program specifically aimed to assist women with historically poor breast cancer outcomes, helping improve the access low-income women had to breast cancer screening and follow-up care.
A ‘critical’ decision
This decision by CMS is critical because patient navigation services largely have been funded in health care systems by grants, philanthropy or departmental budgets, limiting their expansion and long existence.
The long duration of patient navigation is critical.
As Freeman and Rian L. Rodriguez MPH, co-wrote in a paper published in 2011 in Cancer: “Disparities occur when beneficial medical interventions are not shared by all. Moreover, health disparities arise from a complex interplay of economic, social, and cultural factors. ... These causal factors impact on all aspects of the health care continuum, from prevention, detection, diagnosis, treatment and survival to the end of life.”
Nurse navigation is part of the solution to reducing or eliminating disparities when taking these factors into consideration.
Of course, navigators are only part of the solution. The whole issue of social determinants of health also play a role. Economic stability, education and health care access, the neighborhood environment, and social and community context all come into play.
Better late than never
In our own cancer center, the current model of cancer care management involving nurse navigation and social work was implemented in early 2000s.
The program was never intended to take the place of the practice staff, but rather to provide an additional layer of support and resources.
The role of the navigators has been to identify barriers to cancer care, support timely access to that care, and assist patients and their families with communication to the multidisciplinary oncology team.
The navigators are a critical component of our 12 multidisciplinary disease site centers.
As stated above, our nurse navigators are available to patients from the time of new diagnosis through the continuum of care based upon an assessment of the patient’s needs.
In our program, each nurse navigator covers 130 patients on average. That can be overwhelming to say the least.
As Freeman and Rodriguez wrote in the Cancer paper, the spectrum of navigation varies. Some services can be provided by trained lay navigators, whereas other services must be provided by nurses, social workers or other professionals.
“Another principle to take into account is that health care providers should ideally provide patient care that requires their level of education and experience; they should not be assigned to duties that do not require their skills,” they added.
Well, it took us 35 years but — as the saying goes — better late than never.
There is no question that more work needs to be done, and let’s hope that doesn’t take another 35 years.
Stay safe.
References:
- Freeman HP, et al. Cancer. 2011;doi:10.1002/cncr.26262.
- Frelick RW, et al. Oncology Issues. 2017;doi:10.1080/10463356.2006.11884276.
- Knudsen KE and Kamal A. CMS starts paying for patient navigation; ACS offers navigation credentialing program. Available at: https://cancerletter.com/conversation-with-the-cancer-letter/20240105_1/. Published Jan. 5, 2024. Accessed Jan. 30, 2024.
- Petrelli NJ. J Am Coll Surg. 2010;doi: 10.1016/j.jamcollsurg.2009.11.015.
For more information:
Nicholas J. Petrelli, MD, FACS, is Bank of America endowed medical director of ChristianaCare’s Helen F. Graham Cancer Center & Research Institute and associate director of translational research at Wistar Cancer Institute. He also serves as Associate Medical Editor for Surgical Oncology for Healio | HemOnc Today. He can be reached at npetrelli@christianacare.org.
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