While praising the scientific advances that have extended the lives of 14.5 million cancer survivors, a sobering new report from the American Society of Clinical Oncology (ASCO) finds the cancer delivery system is “ill-equipped” to bring these advances to all Americans. The new report, “The State of Cancer Care in America 2016,” was released at a Congressional briefing on Capitol Hill and published March 15, 2016, in the Journal of Oncology Practice.
“As we release this report, our nation has much to be encouraged about,” said ASCO President Julie M. Vose, MD, MBA, the Neumann M. and Mildred E. Harris Professorial Chair and Chief of the Oncology/Hematology Division in the Department of Internal Medicine at the University of Nebraska Medical Center, Omaha. She cited recent advances that have brought patients “better treatments than ever,” including 15 new cancer drugs available in 2015. But, she cautioned, mortality rates for some cancers (e.g., bladder cancer, brain cancer, and melanoma) have remained steady over the past 10 years, and mortality rates for pancreatic and liver cancer have increased.
Vose added that the combination of an aging population (whose members have comorbid conditions), increasing complexity of care, growing demand for cancer care services, oncology workforce shortages, high costs, and geographical gaps in the availability of cancer care creates a formidable challenge.
Specifically, the new report notes the number of cancer survivors is expected to grow to 19 million by 2024, and that the care of older survivors will become increasingly complex. About 30 percent of the Medicare population—whose beneficiaries are at higher risk of cancer—have 3-4 comorbid conditions and nearly 50 percent of dual-eligible Medicare/Medicaid beneficiaries have five or more comorbid conditions. The report also notes nearly 18 percent of oncologists active in patient care are nearing retirement at age 64 or older, and older oncologists continue to outnumber the 13.9 percent of oncologists under age 40 who have recently entered the field.
Vose said ASCO is especially concerned about the rising costs of cancer care, including patient co-pays and deductibles. The report notes a single cancer drug can cost nearly $300,000 per year, and that overall U.S. cancer costs are projected to rise to $173 billion by 2020. “I've had many patients who skip days on their medications” due to high costs,” she said.
Agreeing on the cost burden of cancer drugs was Blase Polite, MD, MPP, Associate Professor of Medicine in the University of Chicago Biological Science Division and Chief Quality Officer of Hematology and Oncology. He pointed out IV cancer drugs are covered well by Medicare, but oral cancer drugs covered under Medicare Part D have escalating co-pays that can constitute a heavy burden for patients.
ASCO supports the Cancer Drug Coverage Parity Act and the Patients' Access to Treatments Act, two pieces of legislation that address and aim to resolve this cost differential, including patient co-pays, of coverage for IV drugs compared to oral drugs. “We do not believe the answer is to put the burden on the backs of providers,” Polite said, noting oncology practices can go “under water” on cancer drugs when what they pay to stock them is less than Medicare reimburses.
The uneven geographic distribution of cancer care providers is a major concern when it comes to patient access, said Debra Patt, MD, MPH, MBA, Vice President of Public Policy at Texas Oncology, a practicing oncologist in Austin, and editor-in-chief of ASCO's new journal, JCO Clinical Cancer Informatics. She noted, “The burden in rural areas remains great,” since 11 percent of Americans (59 million) live in rural areas, but only 5.6 percent of oncologists practice in rural care sites. Patt said that, “Generally, oncologists are in cities,” and that some 50 percent of oncologists reside in just eight states—both of which create access issues for patients who are not in those eight states and not in cities.
Asked by OT if steps could be taken to encourage oncologists to practice in undeserved geographic areas, Vose said, “It's just difficult to attract oncologists to rural areas... We may have to come up with a new system.” Patt warned, “The need that we see in rural areas is reflective of the need that we'll see everywhere in the coming years.” She said there are some financial incentives to attract oncologists to rural areas, but she pointed out that today cancer care delivery is from not just one oncologist, but from a team of specialty oncologists—and thus an entire team would need to have incentives to locate their practice in a rural area.
Patt said ASCO is also concerned about racial and ethnic gaps in cancer care. “Racial and ethnic diversity is still a challenge,” she said. “Obviously there's an unmet need.” She pointed out African-Americans are 2.5 times more likely to develop cancer than whites, and black men are 27 percent more likely to die from cancer than white men. The new report states that, for the first time in 2015, breast cancer incidence rates were higher for African-American women than for any other racial group—which the report called “troubling” because African-American women with breast cancer are diagnosed at a younger age and have higher mortality rates than other women.
Continued Support Needed
“Do you all sometimes think you're living in a Dickens novel?” asked Rep. Michael Burgess, MD (R-TX), who spoke at the Congressional briefing. “It's the best of times, it's the worst of times,” he said. Burgess championed the repeal of the Medicare Sustainable Growth Rate (SGR), which he called “a sword of Damocles,” and passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 which replaced it. “The SGR was very important—a milestone to achieve,” said Burgess. “I also recognize that the implementation of MACRA is very bit as important.”
Burgess urged oncologists to be actively involved in the implementation of MACRA, whose aim is to ensure greater access and health care quality for seniors, more stable reimbursements for health care providers, and a more fiscally solvent Medicare program. “I just want us, the medical profession, to be in the driver's seat” when it comes to payment reform, he said. “I need your help on this; I need your vigilance on this.” Burgess added that oncologists should be encouraged and not be discouraged by the challenges they face, because the pace of advances in the field will mean that students “in medical school right now will have tools at their disposal no one has ever had before.”
Rep. Gene Green (D-TX) also stressed the possibilities of making more inroads against cancer, citing the increased access to care provided by the Affordable Care Act (ACA). While it “wasn't perfect and didn't work as well as we wanted it to,” Green, a ranking member of the Health Subcommittee of the House Energy and Commerce Committee, praised the ACA and said that hopefully it can be expanded in the coming years. The ASCO report notes recent data show that, since the ACA went into effect five years ago, the number of uninsured Americans has decreased by about 17 million. But the Congressional Budget Office estimates about 35 million non-elderly adult Americans were without health insurance in 2015. This number includes low-income people living in states that did not expand Medicaid, those without employer-based health insurance, those who chose not to purchase health insurance in the ACA marketplaces, and undocumented immigrants.
Peggy Eastman is a contributing writer.
ASCO Cancer Care Recommendations
- Ensure all publicly funded insurance programs offer consistent and appropriate benefits and services for cancer patients.
- Test multiple innovative payment and care delivery models to identify feasible solutions that promote high-quality, high-value cancer care. ASCO has sent a statement to Congress expressing concerns that high-quality cancer care for Medicare beneficiaries may be impeded by new reimbursement methodologies as implementation of MACRA moves forward.
- Advance health information technology that supports efficient, coordinated care across the cancer care continuum. Specifically, ASCO is urging that Congress require vendors to create products that promote interoperability.
- Recognize and address the unsustainable trend in the cost of cancer care. To address the fact that costs associated with cancer care are rising more rapidly than costs in other medical sectors, ASCO urges Congress, payers, and professional organizations to work together to find viable solutions to stop this unsustainable trend.