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 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.

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 understanding 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 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 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.

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).

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 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, although 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).

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 (more...)

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 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 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 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 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.

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, (more...)

The committee recommends that professional societies identify and publicly disseminate evidence-based information about cancer care 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 representing 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 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 demonstration 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).

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 (more...)

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.

TABLE 8-1

Examples of Payment Reform Models Relevant to Cancer Care.

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.

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 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 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.