Coverage from the Association of Community Cancer Centers 2022 Annual Meeting and Cancer Center Business Summit, held in Washington, DC, March 2-4.
Comprehensive Cancer Care Adds Value, but Challenge Is Paying for It, ACCC Survey Results Show
There are no billing codes for more than one-third of the supportive care services provided to deliver comprehensive cancer care, half of the participants in a survey by the Association of Community Cancer Centers (ACCC) reported. The survey results were presented March 4 during the 2022 ACCC Annual Meeting & Cancer Center Business Summit in Washington, DC.
Presenters outlined the survey results and offered perspectives on how social workers and pharmacists can support cancer care teams while addressing issues of health equity. Krista Nelson, MSW, LCSW, OSW-C, FAOSW, president of ACCC and program manager at Providence Health & Services in Renton, Washington, chaired the session.
“We know that supportive care and comprehensive cancer care [are] the right things to do,” Nelson said. “We know that if we pay attention to the issues that [affect] patients related to social determinants of health, they will have better outcomes.”
Al B. Benson III, MD, FACP, FASCO, professor of medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois, presented the topline results from the survey, which will soon be published. Benson said the reimbursement challenge puts community cancer practices in a quandary. Comprehensive cancer care required for accreditation can be difficult to fund, he said, because community programs often have less access to philanthropy than academic centers.
“The survey responses demonstrated that programs are not getting reimbursed adequately and in some cases cannot offer these services at all,” Benson said.
The survey was administered from August 2019 to March 2020 with the following results:
Respondents were asked about 27 specific services required for comprehensive cancer care certification; 50% of the respondents said 10 of these services had no billing codes and 8 had limited or underutilized billing.
Even in OCM practices, Benson said, there was a lack of centralization to gain information on how the practice offered essential supportive oncology services.
Role of the Oncology Pharmacist
Olalekan Ajayi, PharmD, MBA, chief operating officer of Highlands Oncology Group in Fayetteville, Arkansas, discussed the expanded role of the oncology pharmacist on the cancer care team. Pharmacists help patients and physicians understand potential adverse effects and drug interactions as oncology regimens have become more complex. Pharmacists can take an active role in practice management as well as formulary management, including promoting the use of biosimilars to achieve cost savings. But Ajayi said perhaps the greatest focus today is medication adherence, due to the rise in the use of oral oncolytics.
“There are still so many other things that pharmacists do in genetic counseling, research,” Ajayi said. “It’s really a very exciting time to be a pharmacist.”
Nelson noted the importance of the oncology pharmacist in research. “If we want to know the clinical trial is valid, we need to know the patients took the medicine,” he said.
Case for Social Workers
Making the case for funding social work were Jennifer Bires, MSW, LCSW, OSW-C, executive director of Life with Cancer and Patient Experience at Inova Schar Cancer Institute in Fairfax, Virginia; and Courtney Bitz, MSW, LCSW, OSW-C, director of clinical social work at City of Hope in Duarte, California.
“Patients are coming to us with more and more struggles,” Bires said. Language differences, unsafe housing, food insecurity, transportation issues all can interfere with a treatment plan or the ability to communicate with the oncologist.
And it’s not just patients who are stressed. “Medical providers are asked to do more than ever,” Bitz said. When an oncologist is seeing dozens of patients a day, having a social worker available to answer questions can be essential, she said.
The oncology social worker is the primary provider of interventions that can alleviate distress, Bitz said. These are things that can affect not just the patient but also caregivers, and research shows all of this affects health outcomes, she said.
The current focus on health equity makes social workers essential. Sometimes what appears to be an immediate barrier—for example, an individual with a substance use disorder being denied a certain pain medication—could lead to a broader discussion about using community resources and addressing a patient’s larger needs, Bires said.
The challenge with social work is funding the staff, Bitz said. She has developed a model that is being replicated elsewhere for funding social work, but in most cases, social work is paid out of the operating budget. Bires said risk stratification is important. Not every patient with cancer will be able to see a social worker, but health systems and cancer centers must work to ensure those with the greatest needs get support.
But it’s important that social work is part of a well-conceived plan. Hiring a single social worker to support a huge team of oncologists or a piecemeal program will not succeed and will not generate patient satisfaction or cost savings, according to the panelists.
“I think putting supportive care in your business plan from the beginning is one of the most important pieces,” Bires said.
In Today’s Prior Authorization System, “Coverage Is Not Access”
Prior authorization requirements in cancer care have become so burdensome that payers are essentially making coverage decisions one case at a time, according to a panelist in the March 3 session “Prior Authorization: How the Sausage Is Made” during the 2022 Association of Community Cancer Centers Annual Meeting & Cancer Center Business Summit in Washington, DC.
The session panelists collectively said the system needs a lot of work. Andrew Hertler, MD, chief medical officer of New Century Health, said the system was intended not just to make sure treatments are necessary but also to ensure that practices get paid.
But other panelists said prior authorization requires practices to make costly investments in personnel and software to navigate payer requirements, and they argued that the shift toward practices assuming risk should make this bureaucracy obsolete.
Prior authorization has become so broken in health care that, “coverage itself is not access,” said John Hennessy, MBA, CMPE, senior vice president and strategist at Valuate Heath Consultancy. He explained that prior authorization transactions happen all the time but most are seamless, such as handing a credit card to a hotel clerk who makes sure the bill can be paid before checking in a guest.
In health care, the process is both slow and unpredictable. “Prior authorization at some point was meant to protect people from low-value experiences,” Hennessy said. “When those transactions happen poorly, and they happen with great uncertainty, that value is lost.”
When a practitioner or patient is repeatedly told “no,” they may assume that the services or drugs they cannot have must be really good. Thus, by their behavior, payers are communicating the wrong message, Hennessey said.
"That part of the process is broken,” he said.
Lalan Wilfong, MD, a medical oncologist at Texas Oncology, and vice president of payer relations and practice transformation at McKesson Specialty Health, said he’s heard all the payer claims that the next portal will be better—and it’s never true. But most of all, he said, prior authorization represents “inserting an entity into care that’s getting between you and the patient.”
“There’s got to be better solutions,” Wilfong said.
Ira Klein, MD, MBA, FACP, vice president of medical affairs and payer relations at Tempus Labs, moderated the panel. Klein, who previously worked for a payer, said there’s an appropriate role for prior authorization—if the payer is administering claims for a self-insured employer, for example, a stop-loss insurer must be informed before a claim gets too large. But when patients receive a diagnosis of cancer and are then told that it’s not clear they can get the diagnostic testing or therapy their doctor recommends, that upsets them.
Are There Solutions to the Current System?
Wilfong said he doesn’t see an issue with documenting the reasons for going off guidelines when that occurs in a small percentage of cases. Regional payers are more willing than national payers to be flexible in giving practices freedom to avoid prior authorization in exchange for assuming risk, he said. Texas has also created a gold card system, which exempts practices from prior authorization if 90% of their claims were approved in the previous 6-month period.
Hertler sees possibilities with artificial intelligence, which would use information from the electronic health record to speed decision-making. But when conversations are needed, Hertler said oncologists should get to speak with other oncologists at the payer level instead of having to explain the need for a drug to a medical director with no background in cancer care.
“It’s a trust-and-verify system,” Wilfong said.
Hennessy said prior authorization shouldn’t be used as a hammer to replace the fact that some payers have poor pricing in some regions or at some hospitals.
Finally, Wilfong said, payers have to stop subjecting practices that have assumed risk to the misaligned incentives found across health care. He used an example currently roiling many oncologists: Anthem is telling practices they must use higher-cost rituximab (Rituxan) instead of lower-cost biosimilars.
“Using prior authorization for formulary management is inappropriate,” he said. “We all know exactly what’s going on here.” Practices, he said, will be forced to carry more brands of rituximab and have more refrigerators, and nurses will have to know more formulations.
Hertler agreed, saying that rebates threaten to undermine the ability of practices to manage costs with biosimilars. “The rebates go one place, and someone else is paying the cost,” he said. “If I could eliminate rebates from the world, I would.”
He sees hope in approving bundles of care; for example, a patient with non–small cell lung cancer would be approved up front for diagnostic testing, scans at designated intervals, and a course of treatment.
Panelists discussed abuses with step edits, and Klein sees challenges in the diagnostic space.
“It’s not about which is the best product, but which has the best rebate for the payer,” Hennessy said. “If someone takes offense, I’m sorry, but that’s what’s going on. One of the challenges, as we try as providers of care to take care of patients, is to simplify this process. Sometimes things outside of our control make it a lot more complex. And prior authorization, in some cases, becomes almost a contract negotiation on a patient-by-patient basis.”