Progress and Momentum to Improve Patient Access to Quality, Timely Cancer Care

Admitting she might sound like an eternal optimist, Alyssa Schatz, MSW, vice president, Policy and Advocacy, National Comprehensive Cancer Network (NCCN), spent the fireside chat on day 1 of The American Journal of Managed Care^®’s annual Patient-Centered Oncology Care^® meeting highlighting the progress she’s seen around responses to prior authorization (PA) policies and movement on equity. However, she also noted some concerning areas, such as ongoing cancer drug shortages.

Alyssa Schatz, MSW | Image credit: NCCN

In conversation with Schatz, David Eagle, MD, chair of legislative affairs and patient advocacy, New York Cancer & Blood Specialists, asked about the evidence of guideline-directed care and the impact of PA on it. Schatz said that all the evidence she’s seen has shown guideline adherence improves overall survival and quality of life for patients, but NCCN also considers the impact of its guidelines on cost to patients, payers, and the health system.

“Guideline adherence is established in literature as also reducing costs,” she said. “So, we know that when we have guideline adherence, we are doing what's right for patients, and we're also doing what's economically right, and I think that's the reason that a vast majority of payers do use NCCN guidelines for coverage determinations.”

As many as 85% of covered lives in the US are covered by a payer who uses NCCN guidelines, but there is still PA, step therapy, and other utilization management techniques layered on top that make accessing care more burdensome for patients and providers.

Where she is hopeful around PA is some recent policy changes. CMS instituted a new rule that requires a PA decision be returned within 7 days on routine care and within 72 hours for more urgent care, which oncology often falls into.¹ This PA ruling doesn’t apply to drugs, however.

In addition, states are introducing and enacting policies. Gold carding is one new policy under which guideline-adherent physicians are “gold carded” and exempt from PA requirements for those services. Texas has had a gold card law for years,² and Wyoming is the latest state to pass the law.³ UnitedHealthcare even announced its own gold card program that will take effect on October 1, 2024.⁴

David Eagle, MD

Image credit: New York Cancer & Blood Specialists

Eagle noted that New York also passed a law that during a clinical peer review to obtain PA approval or appeal a denial, the other provider on the peer-to-peer call now must be trained in the same profession, meaning a family physician wouldn’t be making decisions on oncology case.

“There's also a host of state-level legislation around transparency for prior authorization processes, making sure everybody has the information that they need to move quickly through that process,” Schatz said. “So, these are all first steps, but I think we have positive movement and need to keep our advocacy up.”

Health equity is another area where she feels good about the progress being made. She said equity is essential to NCCN’s mission to improve and facilitate quality, effective, and equitable cancer care.

“We know that we don't live in a world where everyone gets the same access to optimal cancer care today, and as a guideline organization, that means that our mission can't be achieved,” Schatz said.

From a guidelines perspective, NCCN has made certain changes to promote equity, such as using welcoming, respectful, and inclusive language in guidelines. It’s moved away from gender-based language to organ-based language. NCCN also convened the Alliance for Cancer Care Equity with professional societies, patient advocates, and community-based organizations to work on federal advocacy to improve representation in clinical trials, access to patient navigation, and screening rates for screenable cancers.

NCCN also has a Health Equity Report Card, which measures and incentivizes equitable care across 4 domains with 19 measures. An academic pilot project of use of the report card at 5 NCCN cancer centers just wrapped up, and next, NCCN is launching the report card with community sites.

“I personally feel like over the last few years, there's been this call to bridge our health and our social systems, to bridge our health care systems and our communities,” Schatz said. “And I really feel like practices have been rising to meet that call.”

Practices are working on patient navigation services, community engagement teams, and hiring within the community to build trust.

At the federal level, CMS is promoting equity with its new patient navigation codes called Principal Illness Navigation. These help patients with high-risk conditions, like cancer, connect with clinical and support resources.⁵ Schatz added that CMS has also introduced codes for community health integration services and social drivers of health screening.

“I think that's a real win,” she said. “CMS has made it very clear over the last few years that [it is] deeply committed to advancing health equity, and I think that we, as an oncology community, have a lot that we can build on from that commitment.”

However, on the less positive side, she acknowledged there has been backlash to the equity work being done. With a new administration coming into the White House next year, she called on the oncology community to “work together to make sure that cancer stays front and center, and that commitment to advancing cancer care is top of mind. And also, making sure that all the gains we've made on health-related social needs and equity continue to move forward.”

The other area of concern Schatz noted was around drug shortages. In February 2023, a shortage of the chemotherapy drugs carboplatin and cisplatin began to affect patients and providers in the US.⁶ NCCN surveys of institutions found that recently these 2 drugs were no longer in a widespread shortage, but there were other drug shortages. The results published in June 2024 showed 89% of cancer centers reported shortages of at least 1 type of systemic therapy.⁷

“If this is happening at our member institutions, we feel it's likely exacerbated in community settings as well," Schatz said. While it’s good that carboplatin and cisplatin are no longer experiencing shortages, it’s important to continue letting Congress know that the root cause isn’t fixed. “If we don't take, I think, urgent action, we're likely to continue to see recurrent drug shortages. It's going to happen again.”

To conclude, she urged collaboration across stakeholders for advocacy efforts.

“I think we only get to good public policy when we have every different facet and perspective understood and informing the policy,” Schatz said. “Anytime we leave somebody out, there are going to be unintended consequences with the policy that we pass.”

References

1. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F. CMS. January 16, 2024. Accessed September 12, 2024. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

2. Robeznieks A. New physician “gold card” law will cut prior authorization delays. American Medical Association. September 15, 2021. Accessed January 23, 2023. https://www.ama-assn.org/practice-management/prior-authorization/new-physician-gold-card-law-will-cut-prior-authorization

3. Dudley D. House passes bill to rein in insurance providers. Wyoming Public Media. February 20, 2024. Accessed September 12, 2024. https://www.wyomingpublicmedia.org/politics-government/2024-02-20/house-passes-bill-to-rein-in-insurance-providers

4. Introducing a first-of-its-kind national Gold Card program. UnitedHealthcare. September 1, 2024. Accessed September 12, 2024. https://www.uhcprovider.com/en/resource-library/news/2024/qualify-national-gold-card-program.html

5. Pranathi S, Gortman P, Cortez J, Davidson M, Allo M. CMS creates new codes to reimburse for navigation services. Avalere. March 11, 2024. Accessed September 12, 2024. https://avalere.com/insights/cms-creates-new-codes-to-reimburse-for-navigation-services

6. Flinn R. Health care practitioners push for legislative solution to prevent chemotherapy shortage “Groundhog Day.” Am J Manag Care. 2024;30(spec no. 4):SP353-SP354.

7. New survey from NCCN finds cancer drug shortage management remains a moving target, impacting clinical trials. NCCN. News release. June 26, 2024. Accessed September 12, 2024. https://www.nccn.org/home/news/newsdetails?NewsId=4620