Care Access, Centers of Excellence, and the ACA: Expert Interchange at the NCCN Policy Summit

Restrictions in patient access to care—due to geographic location, cost, or health plan coverage—can result in inequities that contribute to health disparities. Some of the factors that define healthcare access include coverage (insured or not), services (access to care services), timeliness, and workforce (shortage of physicians or physician burnout).

At the recently held NCCN Policy Summit on Value, Access, and Cost of Cancer Care, healthcare policy experts discussed the impact of access on the treatment of cancer. Moderated by Scott Gottlieb, MD, fellow at the American Enterprise Institute, who recently participated in The American Journal of Manages Care’s Oncology Stakeholders Summit, panelists included Elizabeth Carpenter, vice president, Avalere Health; Robert Diasio, MD, director, Mayo Clinic Cancer Center; Kavita Patel, MD, fellow and managing director, Engelberg Center for Healthcare Reform, Brookings Institution; Mike Taylor, MSHA, AON Hewitt Health and Benefits; and Julie Wolfson, MD, MPH, University of Alabama at Birmingham.

Ms Carpenter opened up the discussion referring to a recent collaborative report that surveyed participation of leading academic cancer centers in exchanges in different states across the nation. The survey contradicted initial thoughts on narrow networks and found that nearly 75% of the surveyed “academic centers of excellence” were on at least some of the exchange plans. “We need more data after corrections for 2015, which can be obtained with additional transparency in the system,” said Ms Carpenter. A separate analysis comparing exchanges with commercial networks found that exchanges had 34% fewer oncology providers, she added.

Dr Gottlieb asked the panel whether narrow networks are a more common issue for oncology. Dr Patel said it’s important to understand what’s happening with Congress and the pressures on Medicaid’s long-term sustainability. “We knew states would be able to stand up their own exchanges. With the concept of individual markets, especially in oncology, it was thought that the ACA [Affordable Care Act] could solve access issues,” she said, adding that we have to think about the higher out-of-pocket costs and problems faced by community oncology.

“ACA had language around bundled payment—but all services cannot be bundled. In cancer care, we can think about access to cancer drugs, cancer payment reform, and guardrails around network access regardless of payer types,” said Dr Patel. She thinks that some provisions of the Medicare Access and CHIP Reauthorization Act have placed hard targets for oncologists to meet with respect to risk-based payment models, and thoughts such as, “Would referrals hurt me in the end?”

Dr Gottlieb directed the conversation to employers and their thoughts on meeting goals of the ACA. “Some of the more attuned employers are thinking about creating centers of excellence and improving care quality,” said Mr Taylor, “but employers are on the sidelines with oncology, with so much else going on with payment reform and new delivery systems. So unfortunately further efforts for employer education are necessary to make them understand that there’s value in steering people to these specific centers.”

Dr Patel added that employers as well as payers do not seem to want to deal with the outreach and educational efforts. “You want to define value and yet we don’t know what that is. With the complexities of cancer care, insurers too are struggling with what it’s going to look like,” she said.

In response to a question on the impact of public exchanges on private exchanges, Mr Taylor said that networks are broad PPOs, but he’s not sure if particular attention is currently being paid to including or excluding academic centers within these networks. “There is definitely a trend toward narrow networks in private exchanges. Network issue is currently the biggest one, and we are certainly going to see them narrowing,” he added. The fact that carriers are carrying more networks than they’d like is creating administrative challenges, explained Mr Taylor, and they are titrating on their end down to different disease conditions.

According to Ms Carpenter networks are smaller and they have sometimes excluded centers of excellence. “But building networks around the centers of excellence is important,” she emphasized. “Private exchanges are doing everything an employer would do; the distinction is that the employee is in the driver’s seat—he’s the one making the choices.”

“Will CMS [Centers for Medicare and Medicaid Services] be as aggressive with bundling payments in oncology?” asked Dr Gottlieb. Referring to an opinion piece by Ezekiel Emanuel, MD, PhD, where he proposed that 90% of healthcare should be bundled, Dr Patel said, “When you can monitor and see that there’s a possibility of a bundled approach, while saving money, that’s a win-win.” While there are no concrete plans yet for a mandatory oncology bundle, she explained that the Oncology Care Model proposed by the CMS and Oncology Medical Homes that are currently being evaluated at various medical centers are potential approaches to a bundled model.