At the 2020 American Society of Clinical Oncology (ASCO) Virtual Scientific Program(May 29-31, 2020), the Association of Community Cancer Centers (ACCC) presented the preliminary results of a member survey on barriers to resource and reimbursement to comprehensive cancer care delivery.
Journal of Clinical Pathways spoke with Al Bowen Benson III, MD, FACP FASCO, professor of medicine, Feinberg School of Medicine, Northwestern University, and presenter of the survey results, about the depth of these barriers and how future cancer care models can be designed to better promote access to comprehensive care services.
Can you describe the inspiration and purpose behind the ACCC member survey on resource and reimbursement barriers to comprehensive cancer care?
Dr Benson: The ACCC is very interested in making sure that patients have equal access to all aspects of comprehensive cancer care. Discussions around this access have begun to surface more often, particularly around issues such as financial toxicity, affordability of care, and also certain services such as genetic counseling.
We are mindful that many programs cannot offer all of the essential elements of comprehensive cancer care. As bundled payments and oncology care models continue to evolve, we want to make sure that all aspects of comprehensive care are included in future models.
Models of care often focus on cost of care for items such as imaging, laboratory procedures, and various drug treatments, but comprehensive care encompasses so many other elements of care.
With this understanding, we sought to get a sense among ACCC members of barriers to access and limitations to services they could offer. Additionally, with the growing pressure on community practices to join hospital systems or other networks in order to stay afloat, we wanted to come to a better understanding of how practices finance these services without sufficient reimbursement and whether these services are routinely available.
What types of questions were included in the 22-question survey that was disseminated to the ACCC members?
Dr Benson: The survey was divided into four sections, the first of which dealt with demographics. Respondents were asked to describe the type of institutions they were representing, how many clinicians are staffed in the institution, whether they were participating in the Oncology Care Model, and the percentage of care that was insured in the past 12 months.
The next section looked at the availability and offerings of supportive care services, described in terms of percentages. Included in this questioning was screening to identify needs for cancer patients (eg, emotional distress, physical symptoms, pain management, fatigue, financial needs, family needs, and smoking sensation). We also asked about the location of services being offered, particularly for counseling and navigation, fertility preservation, nutrition, pharmacy services, and patient education. These are only a few of the services that were listed on the survey; the range of services extended much further.
Within this section, we also asked for reasons that services were not offered. Was there insufficient reimbursement, lack of internal funding (eg, philanthropy), or not enough trained personnel to offer the services?
The third section was for funding and resources in terms of the workforce used to deliver the comprehensive services. This was asked in terms of the percentage of the total available funding at the institution to cover the needs of the patient population. We asked specifically for details on how supportive oncology care is funded. Is it through fee-for-service, embedded in an alternative payment bundle, through a philanthropy, or through access to other internal funds? Additionally, respondents were prompted to give detail regarding gaps in reimbursement for supportive care services. For example, they could indicate that they do not bill for a service because there is no billing code, because they know it will not be paid, or because it is not worth the effort in terms of the expense of billing.
Also included in this section were questions on the staff that provided supportive services. We asked how many staff full‑time equivalents are available and needed to provide these services across disciplines, including physicians, nurse practitioners, physician assistants, nurses, social workers, lay navigators or other lay staff, medical assistants, or unpaid trained volunteers.
The final section dealt with patient-facing care planning. We asked what percentage of patients received a care plan at diagnosis, and for those who did, what types of care plans were received. Then, we wanted to know how these plans were actually provided. Was it through a discussion with the patient, a written document, or a standard form of some kind? Furthermore, we gathered responses on the specifics that went into the care plan, including diagnosis, goals of care, prognosis, types of treatments, and clinical trial eligibility.
In completing the survey, respondents answered how challenging it was to develop a comprehensive multimodality care plan for a patient who is diagnosed with cancer as well as how easy or challenging it is for patients to manage their comprehensive care across specialties.
Is it fair to say that the survey results point to an overall insufficient reimbursement, staffing, and budget means to provide comprehensive cancer care services in the community setting?
Dr Benson: The survey results definitely support that statement. We are in the process of gathering further data, and then we will have a more comprehensive analysis to share. At the end of the day, our interest is in influencing policy discussions around cancer care models.
As care models continue to be amended and created, it will be essential for a cancer program or practice to understand their population. Every practice is different in terms of how many personnel they might need to provide services. A program may have a population that has enormous financial distress. For such a program or practice, multiple personnel will be needed to deal with those issues.
In short, if cancer care models and reimbursement strategies continue to include bundled payments, and as networks continue to absorb various programs and practices (leading to more centralized services), patients may suffer barriers to access comprehensive cancer care services if such are not routinely embedded as components of care models and overall oncology practice.