Reimbursement Changes Seek to Reduce Disparities in Access to Cancer Care

From the moment of diagnosis, patients with cancer, their families, and caregivers, are often afraid and may be overwhelmed. In addition to absorbing this very difficult news, they often face a range of complex decisions and need help—including assistance accessing psychosocial, health coverage, financial, and social support. Patient needs can be especially acute if they lack a robust support system, strong connections in the health care system, and have certain socio-economic needs. This is where oncology patient navigators come in.

Navigators provide individualized help to patients, allowing them to identify appropriate practitioners and providers while accessing necessary care in a timely fashion. Evidence demonstrates that navigation services are a crucial tool in promoting the delivery of high-quality cancer care.

The Association of Cancer Care Centers (ACCC) and its members—as well as a range of other stakeholders—have supported improved reimbursement for these important services. Significantly, the Biden Cancer Moonshot prioritized the availability of supportive services for those touched by cancer, including promoting patient navigation services. At the end of 2023, important progress was made to improve the availability of oncology navigation services when the federal government—through the Centers for Medicare and Medicaid Services (CMS)—and the private sector, through actions of the American Medical Association (AMA)—issued changes to facilitate access to these services for Medicare beneficiaries and those covered by commercial health plans.

What Has Changed?

Medicare Payment Changes

Historically, Medicare generally did not pay for oncology patient navigation services. To offer these services, some cancer care programs and practices relied on other internal or external resources, when available, and continue to do so. In the absence of reimbursement, some practices were not able to offer these services.

As of January 1, 2024, Medicare began reimbursing for the following 4 new categories of navigation and related services. Each address important patient needs, including the needs of patients with cancer:

• Principal Illness Navigation (PIN)
• Principal Illness Navigation Peer Support (PIN-PS)
• Community Health Integration (CHI)
• Social Determinants of Health (SDOH) Risk Assessment

PIN navigation services encompass visits related to certain serious, high-risk conditions, including cancer, that meet certain requirements. Covered CHI services will include coverage of person-centered assessments to better understand the patient’s life story, health education, and coordination of the receipt of services across a range of providers, including home and community-based providers, among other important services. SDOH risk assessments will include assessments for economic stability, neighborhood and build environment, social and community context, and other factors. PIN-PS services include a range of important supportive and health education services, among others. Additionally, Medicare will cover certain services to help train patient caregivers. 

Clarified Reimbursement Guidance for Private Insurers and Other Payers

At the end of 2023, the AMA updated its guidance on the appropriate use of “CPT®” codes to obtain reimbursement for 2 types of oncology navigation services: 

• Clinical navigation services: Focus on clinical care, coordination, and education.
• Patient navigation services: Focus on facilitating access to care related to social determinants of health.

Clinical navigation services are typically provided by licensed clinical staff, whereas patient navigation services may be provided by a variety of individuals, including community health workers.

Why These Changes?

The implementation of these new navigation codes by the CMS are part of the agency’s efforts to reduce disparities in health care. Specifically, they seek to address these 5 priorities within the agency’s framework for health equity:

• Expand the collection, reporting, and analysis of standardized data.
• Assess causes of disparities within our programs and address inequities in policies and operations to close gaps.
•  Build capacity of health care organizations and the workforce to reduce health and health care disparities.
•  Advance language access, health literacy, and the provision of culturally tailored services.
•  Increase all forms of accessibility to health care services and coverage.

Similarly, the AMA’s updated guidance highlights the importance of increasing the use of effective cancer-navigation services to improve support for patients, reduce cancer disparities, and improve health outcomes.

Next Steps

ACCC members strongly support this enhanced reimbursement. Many are actively working to implement these codes in their practices to build upon existing patient navigation programs or begin offering such services. ACCC is working to assist its members as they seek to put these changes into practice—and thereby continue their longstanding efforts to promote equitable access to cancer care and reduce health disparities while delivering high-quality cancer care. 

ACCC will explore how cancer programs and practices can effectively implement these new codes in the upcoming Virtual Oncology Reimbursement Meeting. Click here to register. 

Nicole Tapay, JD, is director, Cancer Care Delivery and Health Policy, Association of Cancer Care Centers (ACCC).