Why Equity Should Guide Cancer Care Investment: Karen van Caulil, PhD

Employers can support better cancer outcomes by investing in innovative solutions that improve access, prevention, treatment, survivorship, and return-to-work support, Karen van Caulil, PhD, explained during an interview at the Community Oncology Alliance Payer Exchange & Innovation Summit earlier this week.

Van Caulil is the president and CEO of Florida Alliance for Healthcare Value. At the meeting, on September 15, she was a panelist during the session “The Employer Perspective: Investing in Innovative Cancer Care Solutions,” during which she and other experts discussed what employers should weigh beyond cost when evaluating new cancer care solutions, as well as the equity considerations that shape which investments reach all patients.

This transcript has been lightly edited for clarity.

AJMC: As you know, cancer care can be a significant cost driver for employers. What makes investing in innovative cancer care solutions worthwhile for employers?

van Caulil: A couple of years ago, the Business Group on Health said, “Oh, wow! Cancer is now the top cost driver for employers.” When I came to the Florida Alliance—it was called the Florida Health Care Coalition back then—15 years ago, it was the top driver. It has been [a cost driver] since the get-go. Literally, my first meeting that I went to, the first day on the job, was about how to identify the patient who had been newly diagnosed with cancer to make sure all the services that were available would be able to be accessed right away and would be able to steer [the patient to them], all those years ago; all the things that we're still talking about today. Now, we have so much innovation available to help get around some of the challenges and barriers that we had with it. Are they getting the right diagnosis? Are they getting the right care that matches that diagnosis and their genetic makeup?

For employers, certainly, it's a cost issue. We're seeing more and more of their plan members being diagnosed with cancer in later stages and at younger ages, so it's even a bigger number of their workforce who are being impacted. But I want to make sure that folks understand that employers don't just think about it as a cost issue. I mean, they care very deeply about their workers.

They care about, certainly, what kind of experience they're having in accessing their benefits to access their care. They want to make sure they're getting high-quality [care]. They want to make sure that it's timely access, because they know in the end the outcomes will be better for the patient. Hopefully, they'll be able to get them back to work, and maybe even during cancer treatment, but being able to get back to their lives, so it's just imperative that employers stay on top of the emerging technologies and therapies.

AJMC: How do considerations around health equity and access influence the cancer care solutions employers choose to invest in?

van Caulil: An interesting quote that came up during the Payer Exchange & Innovation Summit was that “innovation isn't innovation at all unless all patients can have access to it.” I thought that was just a really good way to look at the situation, because there's a lot of backdoor access to care. I know I get calls all the time to say, “My husband, my wife, me, my child, my mother, my father has just been diagnosed with cancer, and I can't get in and get that appointment for a few weeks. Karen, can you help? Can the Florida Alliance help?” We can pick up the phone because we do know people—whether that's a Center of Excellence or it needs to be community oncologists—to be able to say, “Is there anything that we can do to expedite it?”

But it really got me thinking when I heard that; it can't just be backdoor. It can't be one-off. We have to strive for the fact that everybody is getting access at the same time. From an equity standpoint, really looking at the employer is looking at their data by different demographics to be able to say, “Are all of our plan members across age, race, ethnicity, and occupation getting screened in a timely manner? Are they getting their primary care visits? If there's any discrepancy there, why? What's going on there?” Consider a constant evaluation of making sure that there aren't barriers. Maybe it's the community that people live in, maybe it's cultural, maybe it's language. So, there's a lot to take in when you're looking at access and equity.

AJMC: Where do you see the greatest opportunities for employers to support cancer prevention, early detection, and timely access to treatment?

van Caulil: We have really been doubling down on the concept of advanced primary care. With regular primary care, maybe your annual well visit is 7 minutes; if you're lucky, it might be 10 minutes long. It's just not enough time to be able to build trust with that primary care provider. It's not enough time to have conversations about important vaccines like HPV for your children or up to a certain age as adults. It's not enough time to be able to really convince folks that they need to go have that colonoscopy. It's not enough time for all those cancers that don't even have screening tests available to get into a conversation about potential signs and symptoms.

For us, advanced primary care certainly helps on the prevention end with looking at lifestyle factors, but that screening and early identification of disease is so important. Then, that advanced primary care already has mental health integrated in. They have navigation. They have social workers. A lot of the pieces that really do help with patients’ cancer journey if someone is diagnosed with cancer. But on that front end, that prevention, screening, early identification, and then steerage to the next steps, we really think advanced primary care is the way to go.

AJMC: How can employers better support employee well-being throughout treatment and survivorship, including helping them through their return to work?

van Caulil: That's a lot of different pieces for sure. We have been educating the employers about the fact that a lot of patients with cancer want to and need to return to work during their treatment. How do you make those accommodations? Certainly, giving them examples of things that they can do, but if they have an on-site or near-site health center—and a lot of them do—to look at the possibility of having their hydration and having their labs done at the on-site rather than having to leave work and go even in the community, but typically to the large health systems.

They have ways that they can help support within, but make sure that you know they're accommodating the individuals. Could they work from home for part of it? Are there other ways to accommodate their needs during that? Then, once they're done with treatment, to understand and encourage the ongoing surveillance and monitoring.

One of the things that we saw when we looked at the data was that once people, the patients, had gotten through their cancer journey, they weren't going to follow up, and that was kind of horrifying to say, “You made it through. What is it now that's happening that you haven't stayed on top of that?” We look to the community oncologists to be able to help with follow-up. Is there anything that we can do so that they do survive and have full lives?

AJMC: What innovations are you most interested in seeing going forward?

van Caulil: There's so much going on right now in the space for patients with cancer. I am intrigued and a little worried about artificial intelligence, so I want to be able to see how that could streamline some of the administrative duties in the practices so that they can spend more time on those wrap-around services that are so needed by patients and their families. So, I would put that at the top. I really do think that there's a lot of opportunity there, and it could be with prior authorizations; it could be with any number of administratively burdensome duties that I'm sure the providers and their team members don't love doing as a priority.

I guess one of the things that is really important that I just want to reemphasize is that for community oncology to understand that each of these employers is very, very different. They have their workers in any number of different configurations. They could all be in one market; they could be spread out all over a state; they could be national; or they could be international. So, it is really hard to have a one-size-fits-all approach.

A really good way to be able to figure out how to have relationships with employers in their particular market is if there is a coalition like ours; come to us, and we could certainly help with getting the right people to the table. There may be strength in numbers in being able to work with the health plans, or the pharmacy benefit managers, or even the health care systems to put something together that really does meet the needs of the patients.