Americans take great cancer care for granted. We pride ourselves on access to the best specialists and the most innovative medicines. And this January we learned of the largest ever single-year drop in the rate of cancer deaths across the country.
The Covid-19 pandemic is putting this success at risk, as is the loss of independent oncology practices, reducing patients’ access to community-based cancer care and increasing their costs.
Half of cancer care in the United States occurs at independent oncology practices, which are owned by physicians rather than hospitals or health systems. These practices often provide their communities with their easiest — or sometimes the only — access to cancer treatment.
For cancer, as with other diseases, access matters. Patients treated closer to home are at lower risk for hospitalization and critical illness. Communities with more independent health care providers also have lower health care costs.
But over the past decade, driven by growing practice expenses and skewed financial incentives, many independent community-based cancer care practices have either closed or been sold to hospitals and health systems. In 2007, four-fifths of oncology practices were independent, now under half are. The speed and scale of this transformation exceeds that in every other medical specialty. Because patients are paying for a greater share of their health care costs than ever before, these changes mean that patients with cancer pay more even as they face reduced choice in providers.
Covid-19 has further stressed practices’ finances. When the pandemic hit, visits to independent community-based cancer care practices plummeted to half of pre-pandemic levels. Chemotherapy administration, which accounts for between half and two-thirds of practices’ revenue, also declined. Although patients have recently begun returning to the office, smaller practices and those in areas with high Covid-19 activity have recovered more slowly. Until a highly effective treatment or a vaccine is widely available, Covid-19 will continue to threaten the stability of vulnerable practices and their patients’ access to affordable cancer care.
So what can be done prevent more closures and maintain American cancer care’s edge? In Thursday’s JAMA Oncology, we propose three solutions to preserve access to exceptional cancer care.
First, identify practices for which relief efforts would have the greatest impact, what we call crucial access independent practices. Such practices may be located in areas where there are few cancer care specialists, may compete in health care markets dominated by a small number of large oncology providers, or may disproportionately care for vulnerable populations such as uninsured patients, those who rely on safety-net programs or live in rural communities, or patients of color.
Second, make available to crucial access independent practices the key drug discount program known as the 340B drug pricing program. It allows eligible organizations to acquire drugs from manufacturers at significantly reduced prices, increasing their margins. With the “buy and bill” system for cancer drugs in the U.S., oncology practices purchase drugs from suppliers, administer them, and are reimbursed by insurers for the average cost of the drugs plus a margin to help cover the costs of their drug-infusion programs.
But not all types of practices have equal margins. Half of U.S. hospitals are eligible for 340B discounts from drug manufacturers. This lowers their drug purchasing costs and, because eligible hospitals can still bill insurers at standard rates, increases margins. The program provides a source of funding meant to support their care of the uninsured and underinsured, but independent practices are ineligible regardless of the patients they serve.
During the Covid-19 pandemic, when millions are likely to become uninsured or switch to Medicaid, Congress could support crucial access to independent community-based cancer care practices by extending them the same discount.
Third, insurers should support all oncology practices through care management payments. These monthly payments are based on the number of patients that practices care for and supplement revenue from traditionally billable services, such as office appointments. Care management payments are important because key aspects of care, such as care coordination and patient navigation services, occur outside of such visits.
Providing a monthly care management payment to cover the costs of these services, which has been a key feature of Medicare’s experimental oncology payment model, would be of value to independent oncology practices. These payments, however, are available only to practices that participate in this model and provide each of six required services. To help vulnerable oncology practices during the pandemic, the Centers for Medicare and Medicaid Services could increase the size of these payments and, for crucial access independent practices that are not yet equipped to provide all six services, offer payments that are proportional to the number of required services a practice offers.
Though Covid-19 has rapidly altered cancer care in many ways, it is still poised to build on recent successes. Even during the pandemic, treatment options for patients continue to expand, and clinicians are increasingly understanding how to safely deliver treatment in the Covid-19 era. Supporting independent community-based cancer care practices now will help promote patients’ access to these, and future, advances.
Zachary A.K. Frosch is a fellow in hematology/oncology at the University of Pennsylvania and an innovation fellow at the Penn Center for Cancer Care Innovation. Lawrence N. Shulman is an oncologist and deputy director for clinical services at Penn’s Abramson Cancer Center. Justin E. Bekelman is a radiation oncologist, director of the Penn Center for Cancer Care Innovation, and a senior fellow at Penn’s Leonard Davis Institute for Health Economics.