Category Archives: Across the Nation

A Misguided Experiment?

By Leah Ralph, Director of Health Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoThe noise around drug costs seems to have gotten louder in recent months, with policymakers clamoring for controls on drug pricing, Congressional hearings calling on pharmaceutical executives to testify, and recommendations from the Medicare Payment Advisory Commission (MedPAC) focused on containing Medicare spending in the context of ever-increasing prescription drug costs.

In early March, the Centers for Medicare and Medicaid Services (CMS) issued a proposal to implement a national demonstration program that would target provider reimbursement and fundamentally change the way Medicare pays physicians and hospitals for Part B drugs. The scope of what CMS is proposing is sweeping. If finalized, it represents a significant departure from the methodology and philosophy underlying Medicare’s current reimbursement system, leading to bigger questions about the most appropriate—and effective—way to curb drug spending.

Mandatory Participation

 CMS has broad authority under the Center for Medicare & Medicaid Innovation (CMMI), created by the ACA, to test different models that would improve quality and lower costs in the Medicare program. However, the agency seems to be pushing the scope of its authority, breaking from past demonstration programs to propose a mandatory model in which all Part B providers–hospital outpatient departments, physician offices, and pharmacies–would be required to participate.

The proposed Part B Drug Payment Model would consist of two phases in which providers would be divided into four groups: three experimental groups and one control group over a five-year period. Phase I would be implemented as early as August 2016 and would mandate that approximately half of all Part B providers would have their reimbursement rates reduced to ASP+2.5% plus a flat fee of $16.80 per drug per day. Importantly, Congressionally-mandated sequestration will continue to apply to payments made under the model. As a result, under the proposal, the experimental group’s actual payment rate will be ASP+0.86% plus $16.53 per drug per day. The remaining half, the control group, would continue to be reimbursed for Part B drugs at ASP+6%. The goal, which policymakers have discussed for sometime, is to eliminate financial incentives for providers to prescribe more expensive drugs.

Ambitious Timeline

The agency’s ambitious timeline calls for Phase II to begin as early as January 2017. Phase II would further divide the control and test groups—creating a four-arm control trial—and overlay a requirement to use value-based pricing (VBP) reimbursement strategies and clinical decision support (CDS) tools to produce Medicare savings. One (unlucky) group of providers will be subject to both the reduced ASP rate and the requirement to utilize VBP tools. These tools might include:

  • Reference pricing: Medicare would set a standard payment for therapeutically similar products.
  • Indications-based pricing: Payment would vary for a drug based on its clinical effectiveness for different indications.
  • Voluntary-risk sharing agreements: CMS would enter into voluntary agreements with manufacturers to link health outcomes with payment.
  • Discounting or eliminating patient coinsurance to encourage beneficiary use of high-value drugs.

Unanswered Questions

Despite a preliminary list of potential tools, CMS failed to describe these VBP approaches in any meaningful detail, leaving many questions about how CMS will develop this methodology and how the agency will make determinations about high-value treatments.

Perhaps most unnerving, providers would be assigned to arms of the trial at random based on their geographic location in Primary Care Services Areas (PCSAs), which are clusters of ZIP codes that reflect primary care service delivery. Although CMS has structured Phase I to be budget-neutral for the Medicare program, among providers, there will be winners and losers: the program is designed to redistribute drug spending by increasing payments to provider specialties, such as primary care, that use relatively inexpensive drugs and decrease payments to hospitals and physician specialties, such as oncology and ophthalmology, that often use more costly drugs. Specifically, under the proposed model, the tipping point is $480–drugs that cost providers more than $480 per day on average would result in lower reimbursement, whereas products costing less than $480 per day would produce higher payments than what is reimbursed today.

The majority of drugs–7 of 10–that would make up the largest reduction in reimbursement are used to treat cancer. Moreover, many of these drugs do not have a lower cost alternative.1

ACCC Takes Action

 On both policy and process, ACCC remains deeply concerned. Rather than working with cancer care professionals to build the infrastructure needed to define quality and value in their cancer programs, CMS has responded to a call for reigning in drug costs with a myopic focus on reimbursement. Our members have partnered with CMS on meaningful payment reform – including the most recent Oncology Care Model – and will soon be dedicating extensive resources to navigating a new, and complex, reformed physician payment system under MACRA.

Oncologists are ready for change, but CMS’ proposal reaches too far, too fast, with seemingly little understanding of the devastating impact this approach will have on community cancer care and patient access.

Early on, ACCC joined with 60 oncology stakeholder groups in a letter to CMS asking the agency to withdraw its proposal. On March 17 ACCC, together with more than 300 state and national organizations, sent a letter to Congress asking policymakers not to move forward with the CMS Part B Drug Payment Model proposal. We recently partnered with the Hematology/Oncology Pharmacy Association (HOPA), the Oncology Nursing Society (ONS), and the Association of Oncology Social Work (AOSW) to caution Vice President Biden about how the proposal would impede the goals of the Administration’s cancer Moonshot initiative.

CMS will accept comments on the proposal until May 9, 2016. ACCC will be submitting a comment letter and urges members to express their concerns to the agency.

Access ACCC resources related to this issue and learn more about our advocacy efforts here.

_________________________________________

This post was updated on April 26, 2016.

Ready or Not. . . More ICD-10-CM Codes Coming October 2016!

By  Cindy Parman, CPC, CPC-H, RCC

Calendar pages and clockThe transition to ICD-10-CM diagnosis coding occurred October 1, 2015, but just like ICD-9-CM we will be seeing additions, deletions and revised codes each October until the U.S. moves to ICD-11-CM. Prior to the ICD-10-CM implementation, there was a code freeze and the code set remained in stasis. Beginning October 1, 2016, that changes. Although the final list of codes that will be effective on that date has not yet been published, there are potentially 1,943 new codes, 422 diagnosis codes with revised definitions, and 305 codes that will probably be deleted.

The public comment period for these planned updates closed on April 8, 2016. Both the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) will review all comments before issuing the final list of new, revised and deleted diagnosis codes in June 2016.

Proposed ICD-10-CM changes that will affect oncology include:

  • The addition of more codes to describe the anatomic sites of gastrointestinal stromal tumors
  • The revision of code definitions for Hodgkin lymphoma
  • Code additions for Castleman disease, mast cell activation syndrome and a specific code to report “Rising PSA following treatment for malignant neoplasm of prostate.”

In many instances an existing ICD-10-CM code will be deleted effective October 1, 2016, and replaced by multiple, more specific diagnosis codes. For example, the code for “Acute vascular disorders of intestine” will be deleted and replaced with 27 more specific diagnosis codes.

The ICD-10-CM Official Guidelines for Coding and Reporting, as well as code update information is located at: http://www.cdc.gov/nchs/icd/icd10cm.htm.

______________________________________________________

Guest blogger Cindy Parman, CPC, CPC-H, RCC, authors the “Compliance” column for Oncology Issues, the journal of the Association of Community Cancer Centers.  She is a principal at Coding Strategies, Inc., in Powder Springs, Ga. Attend an ACCC Oncology Reimbursement Meeting to stay current with the latest trends and updates in oncology coding and reimbursement.

Patient Navigation: 20 Years in Review & My Lessons Learned

by Tricia Strusowski, MS, RN

Patient Navigation Compass for HealthcareIt is amazing how the world of patient navigation has changed over the last 20 years! Fate has aligned me with many wonderful opportunities, and over the years I’ve been honored to be an active participant both in the navigation role itself and in navigation program development. The journey has been a labor of love, a true passion, and extremely gratifying.

I was first introduced to the concept of navigation through my role in case management in the mid-1990s. Identifying the needs of the patients even before their cancer care commenced became a necessity to help transition the patients to the correct level of care. The goal was to provide the best services, decrease duplication of care, contain costs, and increase communication among the healthcare team. The patient and the family were active participants in their plan of care.

Toward the end of the decade, in 1998, my then-employer, Christiana Care Health System, Helen F. Graham Cancer Center, identified the need for “care coordination” for oncology patients and families (navigation was not yet a familiar term). We were one of the earlier adopters of “care coordination” or what we now call navigation. Our team consisted of disease-site-specific oncology nurses and social workers. We were under the “administrative microscope” to coordinate care across the continuum from cancer diagnosis through end of treatment or end-of-life care. After a bumpy start, we developed and then standardized our program.  We created pathways, guidelines, standing order sets, a patient journal, and patient tools, which are now called decision aids.  Learn more here.

Here are some navigation lessons learned over the years.

Lesson learned #1: Create tools and reports to reflect American College of Surgeons Commission on Cancer (CoC) national standards; identify metrics to demonstrate the success of your program. Define your reports and metrics for the staff so that information/data is collected in a consistent manner. 

As a new navigation program we initially made our patients and families too dependent on our services and as our volume increased, the caseloads became unmanageable. The staff became overwhelmed and we needed to address this immediately to provide the best service for our patients.

Lesson learned #2: Empower your patients with decision-aid tools/educational materials and provide health literacy training for staff. Monitor the caseloads and close cases when active treatment is completed. Hold morning meetings or huddles to share patient information with the healthcare team across the continuum.  Keeping your healthcare team updated increases productivity. 

In 2007 Christiana was an original member of the NCI Community Cancer Centers Program (NCCCP) initiative. I co-chaired the Quality of Care Subcommittee.   As a result of navigation discussions we created the Navigation Networking Committee and listserv; we held monthly conference calls to discuss our programs, best practices, document tools, and models of navigation. Our committee grew to more than 90 attendees. It was a fantastic learning and bonding experience; many of us are still close colleagues today. One resource developed through the NCCCP was a Navigation Assessment Tool for growing a program. Learn more.

Lesson learned # 3: Collaborate with your internal and external resources to identify best practices. Use the internal resources/experts in your healthcare system, i.e., pastoral care, finance, volunteer department, etc.  Partner with your external resources, such as the American Cancer Society (ACS), state Breast Cancer Coalition, Leukemia & Lymphoma Society, and Cancer Support Community. 

From 2008 to 2009 ACCC provided me with an exceptional opportunity to teach a two-day patient navigation workshop at six community cancer programs. I met with the teams and we discussed the goals, roles and responsibilities, documentation tools, job descriptions, guidelines, reports, and performance improvement initiatives. The programs were all very appreciative of the information because there really were not many resources available at the time. At the end of these training sessions ACCC held its first webinar on navigation.

Lesson learned # 4: Don’t reinvent the wheel. Today there are many resources available for navigation through ACCC, AONN+, ONS, AOSW, NCI, IOM, and  ASCO, just to name a few.  Network with your colleagues via listservs.

Navigation at times can be a “catch all” service; navigators may get bogged down with scheduling appointments, calling insurers, and data entry as well as other clerical duties.  Although some of these responsibilities are inevitable, it is important to identify support staff to assist with these tasks.

Lesson learned # 5: As a professional navigator it is essential that you function to the top of your license. You don’t want to turn into an expensive clerk.

Today, as I continue my role as independent consultant, I always tell my clients that patients and families always come first. If you take excellent care of the patients using national standards and best practices, the rest will fall into place.

_____________________________________________________

Guest blogger Tricia Strusowski, RN, MS, is a consultant with Oncology Solutions, LLC.

Patient-Centered Care—Empowering Patients, Engaging Providers

Jennie R. Crews, MD, MM, FACPEarlier this month, Jennie R. Crews, MD, FACP, began her tenure as ACCC President 2016-2017. Each ACCC President selects a theme issue. In this blog post, Dr. Crews discusses her President’s Theme: “Patient-Centered Care—Empowering Patients, Engaging Providers.”

By Jennie R. Crews, MD, FACP, ACCC President

As I begin my tenure as ACCC President, I am grateful to my predecessors for their leadership and for their contributions to the Association. They have left a wonderful and evolving legacy of presidential themes: from exploring the developing concept of the Oncology Medical Home; to providing the right care at the right time; to the importance of the multidisciplinary oncology team; to defining quality in oncology care; and, finally, revisiting the Oncology Medical Home theme as it relates to integrated healthcare delivery models. I hope to add to this evolving legacy with a presidential theme that focuses on patient-centered care:  Empowering Patients, Engaging Providers

Over the coming months, there will be many opportunities to explore this theme. While we all think we understand and provide patient-centered care, in our changing healthcare environment we are being challenged to examine how we define patient-centered care—both today and tomorrow. How do we continue to provide patient-centered care as we transition to new models of cancer care delivery? How will the changing role of the patient in consumer-driven healthcare influence what we think of as patient-centered care?

In our day-to-day work, so many of the challenges we face are based in our struggle to deliver patient-centered care:

  • The effort to ensure access to care−especially for patients in rural and underserved areas and for those with limited resources strained by the accelerating cost of cancer care.
  • The growth of personalized medicine with expanded use of genomic analysis and molecular testing and the consequent concerns of how to use this data and how to pay for it.
  • The imperative to meet accreditation requirements, such as survivorship care, and−most important−to ensure that this care is relevant and valuable to our patients.
  • The need to incorporate shared decision-making tools into busy programs to help patients clarify the value of outcomes, understand the financial impact of cancer treatment, and define their end-of-life wishes.
  • The enhanced use of patient-reported outcomes in cancer treatment and symptom management.
  • The implementation of new technologies to share data or provide telemedicine, including smart phone apps and patient portals that give patients new options in how they receive care, but which will require new forms of reimbursement.

To meet all of these challenges we must first involve and empower our patients, engaging all of the multidisciplinary providers on the oncology care team with these efforts. I look forward to working with the ACCC membership this year to explore creative and practical solutions to these challenges that we all face as we strive to keep the patient at the center of everything.

 

A Financial Advocate’s Six Steps to Cost Transparency

By Clara Lambert, Oncology Financial Navigator

Form-with-stethoscopeThe challenges of today’s healthcare environment mean that every patient with cancer can benefit from financial navigation. At some point during their treatment, most patients will have questions about their billing, and how it will affect their personal finances. Make sure your financial navigation process includes meeting with each new patient face-to-face. Whether this meeting is scheduled after their first appointment with the oncologist, or after their chemotherapy teaching and prior to beginning treatment, this face-to-face conversation is an opportunity for financial advocates to introduce themselves, explain their role, and help the patient feel more comfortable asking questions about costs of care early on rather than later when it may be too late to access assistance.

Here are six steps financial advocates can take toward cost transparency.

Step 1. Review All Insurance Benefits.

Before meeting for the first time with a new patient, financial advocates should review all of the patient’s insurance benefits.  This should be a comprehensive review conducted with the patient’s treatment plan in mind. Look at all hospital, medical, and pharmaceutical benefits, as the patient’s treatment could encompass some or all of these benefits.

Step 2. Work with Your Pharmacist & Chargemaster to Develop Price Estimates for More Common Treatments.

Developing price estimates for common treatments can help financial advocates streamline the financial navigation process.  At my facility, our pharmacist worked with our oncologists to develop the most common treatments for each diagnosis following NCCN Guidelines. The financial team is then able to work with that information to develop the price estimates.

Step 3. Personalize the Price Estimate to the Patient.

Taking the insurance review and the previously developed price estimates into account,  financial advocates can develop a personalized price estimate specific to each patient. You may want to develop a form to populate with this information so if the patient wants a copy of the information, it’s ready to go.

Step 4. Always Have a Plan in Mind.

Now that you have reviewed the patient’s benefits and prepared a personalized price estimate for the patient, you are almost ready for that first meeting.  Before meeting with a patient, you should prepare a plan outlining potential assistance.  Be sure your plan includes all of the qualification requirements for financial assistance and also verify that the fund is still open and accepting new applications. This advance work will help streamline the patient meeting, and allow you to start any applications immediately if the patient qualifies and is interested in pursuing financial assistance.

Step 5. Meet With The Patient.

From your very first meeting with the patient, it’s important to build a relationship. In this face-to-face meeting you will be getting to know the patient, as well as letting the patient know that you are there to help. You will need to make sure that your conversations are compassionate and understanding.

During the meeting, you will review the patient’s insurance benefits and the cost estimate for their plan of treatment.  There is often some patient education to help the patient understand his or her insurance benefits. As part of this meeting, complete a financial screening and begin the application process for the programs that the patient qualifies for.  The patient may be feeling overwhelmed with information, so preparing a checklist for the patient to identify any missing items will help them comply with supplying the information. It is best to submit an application for financial assistance when everything is complete, as many foundations will not look at an application until they have received all the required information.

Step 6. Follow Up & Track.

Many programs provide instant approval. For those programs that do not, you will need to set a follow-up reminder.  I typically follow up weekly.  If you receive a denial that you disagree with, know the appeal process, and begin immediately.  Once the application has been approved, make sure you notify the patient and billing personnel, and track the information to show the cost savings to your patient and your facility.

Guest blogger ACCC member Clara Lambert is an oncology financial navigator with Cancer Services at Munson Medical Center, and an active member of the ACCC Financial Advocacy Network (FAN).  Learn about upcoming ACCC FAN Case-Based Workshops here. Explore all of the ACCC FAN resources for oncology financial advocates here.

ACCC Annual Meeting: Five Key Takeaways

by Amanda Patton, ACCC Communications

ACCC 42nd Annual MeetingNearly 500 oncology professionals gathered in Washington, D.C., last week for the 42nd ACCC Annual Meeting, CANCERSCAPE. Throughout sessions centered on policy, value, and quality, attendees heard a recurrent message: Your experience, perspective, and input on the issues of value-based care, quality measures, and outcomes are essential as the healthcare system and oncology transition to the new world of alternative payment models and value-based care.

From ACCC Capitol Hill Day last Wednesday throughout the meeting sessions, attendees were urged to educate policymakers and payers about the real-world processes involved in delivering quality cancer care.

In the meeting’s opening session, Congressman Rick Nolan (MN-D)  called out the vital role ACCC members can play in helping educate legislators and policymakers, “No one can articulate need, challenges, potential to ultimately cure cancer [better] than the people in this room today,” he said.

Can precision medicine be reconciled with value-based care? “Absolutely” said Kavita Patel, MD, MS, of the Brookings Institution.  Oncology already delivers personalized (or precision) medicine through targeted therapies for some cancers, she pointed out. Communicating about the oncology care process so that policymakers understand real-world cancer care delivery is imperative, Patel said. Part of that conversation should aim to help policymakers understand the demanding intuitive thought process that is part of today’s oncology care, along with the tremendous amount of information cancer care providers must keep up with given the pace and variety of emerging therapies. “It’s not writing prescriptions,” she said.

Five Key CANCERSCAPE Takeaways

High-level meeting takeaways that interconnect value, policy, and quality include:

  1. Alignment. For value and quality measures to work in oncology, alignment among payers, providers, and patients is essential.
  2. Put your data to work. Cancer programs and practices are finding ways to harness their data to improve quality patient-centered care and reduce costs. In a presentation on Collaboration Across Specialties to Improve Care and Curb Costs, Matthew Manning, MD,  from Cone Health demonstrated how his program used data to identify “hotspotters,” assess gaps in care, improve outcomes, and reduce costs.
  3. Communicate. Support conversations across silos and among stakeholders. Engage with patients to understand their goals of care and to define value and quality. While value frameworks are generic, “all patients are different” agreed panelists in a Town Hall discussion on Value Framework Tools.
  4. Be proactive. Don’t wait until USP Chapter 800 goes into effect to assess your facilities readiness. Don’t wait until HRSA issues its final 340B mega-regulation. Take steps today to assess your program’s compliance. “Be prepared” was also the message in a Biosimilars Update from Nisha Pherwani, PharmD, BCOP, clinical director of Oncology, Cardinal Health. She urged attendees to:
    • Understand the FDA approval process for biosimilars
    • Provide a concise review to your P&T committee
    • Review the FDA guidances on biosimilars
    • Stay tuned for more on how interchangeability will impact regulations.
  5. Speak up. Oncology providers can best articulate the care they provide and the issues impacting care delivery. Leadership in oncology has to step forward to help define quality and value and inform policy. Work with ACCC to make your voice heard.

This week’s CMS release of a proposed rule designed to test new Medicare Part B drug payment models makes clear the critical need for the oncology community stay on top of what is happening among policymakers in Washington, D.C.  ACCC has voiced strong opposition to CMS’s proposal. Among other concerns, ACCC points to the lack of opportunity for stakeholder input on the development of this proposal.

ACCC urges its members speak up and ask Congress to stop the CMS Medicare Part B Drug Payment Model.  Click here to contact your legislators.

Rep. Nolan Praises Advocacy Efforts of ACCC Members

by Amanda Patton, ACCC Communications

Rep. Richard Nolan opens ACCC 42nd Annual Meeting

Rep. Richard Nolan opens ACCC 42nd Annual Meeting

Congressman Richard “Rick” Nolan (MN-D) opened the ACCC 42nd Annual Meeting on Thursday paying tribute to ACCC membership. “I want to thank you for all that you do,” he said.

“You are part of the team that comes together to be there for people at the most challenging and emotionally difficult and troubling times in their lives. . . Thanks to the dedication and hard work of people like you so much progress is being made in [the fight] against cancer.”

In an ideal transition from ACCC Capitol Hill Day to CANCERSCAPE Annual Meeting sessions focused on policy and key drivers of change, Representative Nolan told attendees coming to Washington is critical, “I know it’s not easy, but it is so important because as a practical matter lending your voices, your knowledge, your perspective is unbelievably important.”

He spoke movingly about the impact of cancer in his own family. Congressman Nolan lost his father to cancer, and an aunt—who was an inspiration for his political career—also died from cancer at age 54.

Last January, he announced that his youngest daughter had been diagnosed with stage 4 non-smoking lung cancer. She is “a high spirited, very determined, and very, very health conscious young woman,” Nolan said. “Thanks to people’s prayers and advances in medical science she’s doing better. She is still with us fighting the good fight.”

His daughter’s struggle inspired Nolan to establish the Congressional Lung Cancer Caucus, along with co-founders Lois Capps (CA-D) and Frank LoBiondo (NJ-R).

Because nearly everyone has someone in their lives who has been touched by cancer, Congressman Nolan is optimistic that “we can find nonpartisan almost unanimous agreement to find better funding for the research needed to end this terrible scourge.”

Advocacy efforts such as ACCC Capitol Hill Day are critical he said. It’s important to tell your story because “no one can articulate need, challenges, potential to ultimately cure cancer [better] than the people in this room today.”

___________________________

Stay tuned for Annual Meeting key takeaways.

Navigation Metrics and Value-Based Care

By Tricia Strusowski, MS, RN

Ms. Strusowski recently co-authored an article on “Patient Navigation Metrics” for Oncology Issues, the journal of the Association of Community Cancer Centers. In this guest blog post, she explores this topic in the context of value-based care.

ThinkstockPhotos-467463476Value-based care is a highly coordinated, patient-centered solution to address rising costs, duplication of services, barriers to care, and to help patients receive the care they need. Over the decades, patient navigation standards and core competencies have been established through national organizations. These guidelines and standards have provided an excellent foundation for oncology navigation programs. Metrics are exceedingly important for measuring the success of your patient navigation program. Value-based care (which drives improvements to the delivery of care by requiring improved care at a lower cost) encompasses more than metrics and has the potential to skyrocket your program to a new level.

As we advance present navigation programs, value-based care will be essential; it will incorporate all the key categories from the Institute of Medicine (IOM) report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.”

The conceptual framework from the IOM report includes:

  • Engaged patients
  • Adequately staffed, trained, and coordinated workforce
  • Evidence-based cancer care
  • A learning healthcare IT system for cancer
  • Translation of evidence into clinical practice, quality measurement, and performance improvement
  • Accessible, affordable cancer care

The goal of value-based care is to empower patients to actively participate in their care, which will enhance the patient experience and drive patient-centered outcomes.

How can we support our patients to participate in their care discussions? Some examples include:

  • Provide decision aides including questions to prompt discussion with the patient and his or her healthcare provider
  • Provide patients with educational information that incorporates their preferred learning style, i.e., written, visual, or verbal
  • Mandate health literacy and cultural competency training for our staff
  • Utilize evidence-based tools to identify barriers for patients and their families
  • Create a patient appointment checklist to explain the reason for tests and procedures

The result of value-based care is a patient-centered process in which patients and their families are educated and able to participate in their treatment discussion from time of diagnosis through to survivorship or end-of-life services. By having our patients actively participate in these treatment discussions, value-based outcomes will prevail and advance the level of our patient navigation programs.

Next week, the ACCC 42nd Annual Meeting, CANCERSCAPE, in Washington, D.C., will feature sessions that focus on various facets of value-based care, including a special Town Hall discussion: Value Framework Tools: The Provider Perspective, which will be live-streamed on Thursday, March 3, 2016, from 12:50 pm — 1:35 pm EST. Learn more here.  

Oral Parity: When Modern Medicine Outpaces Policy

By Leah Ralph, Director of Health Policy, ACCC

PillsACCC has been a longtime champion of oral parity, the legislative effort to equalize patient cost sharing for intravenous (IV) and oral chemotherapy drugs.

Oral oncolytics can offer a better quality of life for patients undergoing chemotherapy treatment, including less travel time, fewer work absences, often fewer side effects, and the convenience and comfort of at-home administration. For some cancer patients, an oral anti-cancer medication is the only option for treatment. Yet insurance coverage has not kept pace with medical innovation. Outdated insurance benefit designs continue to cover oral medications under the pharmacy benefit, which often means high, burdensome out-of-pocket costs for patients. (Traditional IV chemotherapy is covered under a plan’s medical benefit, resulting in minimal co-pays or no cost for patients.) This coverage disparity creates financial burdens for patients prescribed an oral anti-cancer medicine, leaving them less likely to adhere to treatment and often unable to fill their prescription. The number one reason a patient does not take his or her medication appropriately is cost. According to a 2011 study published in the Journal of Oncology Practice and the American Journal of Managed Care, 10 percent of cancer patients failed to fill their initial prescriptions for oral anticancer medications due to high out-of-pocket costs.

Progress at the State Level

We’ve come a long way in terms of state law. To date, 40 states plus the District of Columbia have passed oral parity legislation. These laws are not a mandate to cover oral chemotherapy, but rather require that if an insurance plan covers chemotherapy treatment, a patient’s out-of-pocket costs must be the same, regardless of how the therapy is administered. As a member of the State Patients Equal Access Coalition (SPEAC), ACCC has partnered with several state oncology societies—including Virginia, West Virginia, and Arizona in recent years—to pass oral parity laws, and this year we’re focusing our efforts on Tennessee and South Carolina. (If you are a provider in either of these states, and you’d like to be an advocate, email ACCC Director of Health Policy, Leah Ralph. ACCC participated in this new SPEAC video that helps to tell the oral parity story from the patient’s perspective.

Why Federal Legislation is Necessary

And even though a majority of states have now passed state-level oral parity legislation, federal legislation is still needed. A federal law would ensure that new cost-sharing restrictions are implemented consistently across the country, and that plans that fall outside state regulation, such as those covered under the federal ERISA law (usually large, multi-state health plans), must comply with the same equitable coverage requirements. In September, an ACCC member spoke at a Congressional briefing on the Cancer Drug Coverage Parity Act of 2015 (S.1566/H.R.2739), helping gain critical momentum to move the bill forward.

In a few weeks, at ACCC 2016 Capitol Hill Day on March 2, ACCC members will be walking the halls of Congress to talk with legislators about the importance of this bill to cancer patients and the providers who care for them.

ACCC encourages members to join our efforts, and continue to monitor opportunities to weigh in with your state and federal legislators. For more on this issue, look for an upcoming article to be published in the March/April Oncology Issues, “Exploring the Issue of Cancer Drug Parity.”

 

 

Financial Advocates—Working to Curb the Economic Impact of Cancer

By Amanda Patton, ACCC Communications

Healthcare costsThe financial burden of a cancer diagnosis impacts patients and families at all income levels—insured and uninsured, young and old alike, city folks and those in rural areas. Perhaps nothing communicated this reality more powerfully than last month’s CNN interview with Vice President Joe Biden when he shared the story of how his own family was challenged by the economic impact of his son’s cancer diagnosis. Concerned about providing for his son’s family, the Vice President related how at one point he had considered selling his home and how President Obama offered his financial help.

“Without question, the last challenge cancer patients need to face is the double blow of serious health issues and serious financial issues. Yet “financial toxicity” is increasingly recognized as a potentially devastating side effect of cancer,” writes ACCC President Steven D’Amato, BSPharm, BCOP, in “Curbing Financial Anxiety on the Road to Recovery.”  (The article was published in a special supplement to USA Today distributed in select cities nationwide.)  He describes how many cancer programs across the country are working to curb financial toxicity by adding a new member to the team—the financial advocate—to help patients and providers understand and mitigate the economic burden of cancer.

Increasing Complexity

Since 2012, the Association of Community Cancer Centers, through the ACCC Financial Advocacy Network (FAN), has been creating tools and resources to support these newest members of the multidisciplinary cancer care team. In a healthcare economic environment that is increasingly complex and challenging to navigate—for patients and providers alike—the skill set and role of the financial advocate must change, says Dan Sherman, MA, LPC, clinical financial consultant, at ACCC member cancer program The Lacks Cancer Center.  “. . . we need improvement in this area because even though most hospital settings that provide oncology care having financial counselors who have been tasked to deal with the problem, nonetheless, the problem remains,” he said in an interview published in the 2016 ACCC Patient Assistance & Reimbursement Guide.  Mr. Sherman is a member of the ACCC FAN Advisory Committee.

Evolving Resources

Look for new education opportunities from the ACCC Financial Advocacy Network in 2016 to help cancer programs identify areas of improvement in helping patients and providers cope with the economic implications of a cancer diagnosis, including:

  • Case-Based Workshops providing high-level analysis and fostering collaborative peer-to-peer problem solving. Learn more and register here.
  • Soon-to-be-launched certificate program for financial advocates.
  • Results from the 2015 FAN learning labs for process improvement in financial advocacy services.

According to findings from the 2015 ACCC Trends in Cancer Programs survey, 74 percent of respondents report having a financial specialist on staff.  The ACCC Financial Advocacy Network is here to support these professionals as they work in cancer programs across the country helping patients and families navigate the economic impact of cancer.