Narrow Networks in Cancer Care: Tough on Patients but Here to Stay

Experts at the National Comprehensive Cancer Network Policy Summit discussed the present challenges of transitioning to alternative payment models at a time when the costs of many cancer therapies are rising.

Narrow networks, which limit where patients can receive care, are holding down costs, but the price to patients with cancer and providers in lack of convenience can be high, according to panelists who discussed changes in care delivery at the National Comprehensive Cancer Network’s (NCCN) June 25, 2018, policy summit in Washington, DC.

“The Evolving Healthcare Landscape: Implications for Access to Quality Cancer Care,” brought together leading oncologists, policy experts, and patient advocates to address the conundrum for today’s cancer patient: therapeutic advances mean there are more options than ever, but for many, barriers to the best treatments will be too high.

Joseph Alvarnas, MD, a hematologist/oncologist who serves as vice president for Government Affairs and senior medical director for Employer Strategy at City of Hope in California, said that unlike many other parts of the country, his state has lots of health plans—but that still doesn’t mean a patient will find adequate networks.

“The challenge here is if the motivation is to deliver low-cost care, [health plans] can find a low-cost provider in every market,” said Alvarnas, who is also the editor in chief of Evidence-Based Oncology. Narrow networks can work if there is a commitment to quality, but when price is the only priority, “their decisions are not based on, ‘Where do I get the best care?’ but ‘Where do I get the lowest price?’”

Narrow networks have proliferated under the Affordable Care Act (ACA) because of lower-cost plans sold on the marketplace. And in some cases, that’s left leading academic medical centers and NCCN member health systems on the sidelines, because their costs are considered too high. Alyssa Schatz, MSW, policy director for NCCN, presented research to the group showing that most cancer centers are in some exchange networks, and a few have not been placed in any exchange network.

It’s reached a point that the National Association of Insurance Commissioners, which creates policies and model legislation to bring some uniformity across state lines, needs to revisit the narrow network issue, said Jenny Carlson, associate vice president for Government Affairs at Ohio State University’s Wexler Medical Center.

John Cox, DO, a medical oncologist at UT Southwestern and Parkland Health and Hospital System, agreed that the ACA, while bringing coverage to many uninsured, has its drawbacks. “On the one side, I love that our patients have a secure insurance contract. They have access to care,” he said. But he’s seen examples of patients who must travel long distances, often carrying their medical records with them, to use the lone specialist approved by their plan. “It just puts up tons of barriers,” he said.

All this may be true, said Kavita Patel, MD, a senior fellow at the Brookings Institution, but no one should expect narrow networks to end any time soon. “Our narrow networks are an insurance company’s high-value network,” she said. They are considered a critical tool in controlling costs, so institutions that are left out must work with payers to show why they bring value and should be included.

Moderator Cliff Goodman, PhD, asked if oncologists and patients with cancer must live with narrow networks, what can be done to ensure that consumers are protected?

Both Joe Antos, PhD, of the American Enterprise Institute, and Elizabeth Franklin, LGSW, ACSW, executive director of the Cancer Policy Institute for the Cancer Support Community, said one challenge is the complexity of insurance contracts. If healthcare experts have a hard time figuring out what’s covered and what’s not, how can patients navigate the system?

Most people still get coverage through their employer, Antos said, and when someone is diagnosed with cancer “the patient is locked in” to whatever that plan provides. “Patients don’t know what to do,” to avoid large out-of-pocket costs, he said, “and doctors aren’t very good at telling them.”

Franklin added that many health plans don’t pay for social workers who could help a patient navigate the system.

Goodman asked whether CMS’ push for more of cancer care in Medicare to be provided through alternative payment models, or APMs, would make a difference. In theory, APMs should take a patient’s experience into account when setting reimbursement, not just cost.

Alvarnas said a problem here is that too many providers are simply trying to “game the system” for maximum reimbursement under the Merit-based Incentive Payment System, or MIPS, instead of aiming for excellence. “We should have transparency about what represents excellence, especially in cancer care,” he said.

Patel noted that while the ACA contemplated APMs, they did not exist right after the law passed. MIPS is a tool to get doctors to experiment with taking on risk, because the transition to 2-sided risk in APMs cannot happen all at once. And in cancer care, this transition is happening just as the cost of immunotherapy is skyrocketing, which gives doctors pause. She reminded the audience that the 2015 Medicare Access and CHIP Reauthorization Act, which set up MIPS and the ability of Medicare to pay doctors through APMs, is “budget neutral.” This suggests there will be winners and losers. The problem, Patel said, is “what constitutes a loser?”

Carlson discussed experiments with Medicaid waivers, including the push by some states to add work or volunteerism requirements. She said this will be closely scrutinized in the courts (not long after the summit, a federal judge blocked Kentucky’s plan to add work requirements to Medicaid). Schatz said the bureaucracy associated with Medicaid work rules is quite challenging.

Antos said an overlooked aspect of the ACA is that “it shifted resources, so there were winners and losers.” Some previously uninsured people gained access for the first time, but when not enough healthy people signed up for coverage, some lower middle-class families that were not eligible for subsidies “could no longer afford the coverage they used to have.”

The threat today is that the Trump administration’s decision to eliminate the individual mandate through its tax plan will drive healthy people out of the risk pool. Patel, who worked on the ACA as a member of the Obama administration, said calls for harsher penalties for not enrolling went unheeded. This is a much bigger threat to the healthcare system than association health plans (AHPs), she said.

Franklin sees the AHPs are a real problem. “What happens when a 30-year-old gets cancer?” she asked. For many, the diagnosis will reveal how little their plan actually covers.

In addition, buying cheap coverage will end up being a barrier to accessing the life-saving treatments that are reaching the market, such as chimeric antigen receptor (CAR) T-cell therapies. Anna Griffin of Kite Pharma, developer of the CAR T-cell treatment Yescarta, said, “we’re not allowed to say ‘cure,’ because the data are still young,” but researchers are starting to get results for people 2 years after treatment, “and it still looks really good.”

“It’s such a great time to be in cancer medicine,” Cox said. But the downside is that for patients, there’s no access to bone marrow transplants. Very few cancer centers can take on a charity transplant patient, he said.

“What is not encouraging,” said Franklin, is the prospect of telling patients, “This potentially is a cure, but not for you because you’re poor—or because you’re not near a major cancer center.”

Goodman asked each of the panelists to predict what’s ahead.

Alvarnas said he looked forward to “getting rid of the middlemen,” referring to pharmacy benefit managers (PBMs); reining in pharmaceutical costs, and getting rid of wasteful procedures. He was excited about the upcoming venture among Berkshire Hathaway, Amazon, and JPMorganChase, which could bring analytics to the cause in a more powerful way.

In discussing the Trump administration’s plan to hold down pharmaceutical costs, several panelists said the proposed merger of Medicare Part B and Part D will be much harder to achieve than most realized. Antos pointed out that Part D is very much driven by rebates, which have been a target of scorn among those who believe PBMs are largely responsible for driving up prices. Antos said the extremely high costs of treatment will upset the financing model.

“I’m also concerned about patient safety,” said Franklin. She would like to see patient experience data on drug labels. Carlson foresees a broader use of telemedicine and, she hopes, more streamlined coverage decisions.

Schatz said there’s a great need for transparency of information so that consumers can make more informed choices.

Patel expects that by 2023, “50% of cancer care will be in some at-risk payment model.”

“Patients are going to have some real options in cancer treatment—options that look different than they do today,” according to Franklin.