For many oncologists, providing high-quality, cost-effective care that improves patient outcomes is no small feat — and reimbursement models that adequately encapsulate the complexities of oncology care are few and far between.
Here, six oncology leaders share the biggest reimbursement challenges the specialty faces today.
Editor’s note: Responses are presented alphabetically and were lightly edited for length and clarity.
Joseph Alvarnas, MD, Hematologist-Oncologist and Vice President of Government Affairs at City of Hope (Duarte, Calif.): My greatest concern regarding reimbursement is that the essential value of what oncologists and healthcare workers do in the service of patients and families far too often gets lost in translation. We live in a world in which health has been crystalized and systematized into evaluation and management coded encounters, International Classification of Disease and Current Procedural Terminology codes.
We do not live in that world, nor do the patients and families who have entrusted their lives and well-being to our care. Our reimbursement system far too often follows a shallow, reflexive, blind obeisance to financial constructs that were created in absence of input from those whom we seek to serve.
I have worked as a hematologist at City of Hope for 24 years and every day is a constant reminder of what matters most: the lives, hopes, dreams and aspirations of the patients and families who entrust us with their care. It is a relationship that begins with what can best be characterized as their "dark night of the soul."
The U.S. healthcare system far too often tries to reverse engineer care around the dollar and not enough around the essential values of human life. What we seek is a restoration of human wholeness in the face of a seemingly implacable foe. We embrace a model of care that ensures sometimes-abstract concepts translate into the tangible reality of lives saved, patients' dignity affirmed and honored, and families restored to wholeness.
The needs of our patients, families and their communities transcend any existing convention to metricize the blood, toil, tears and sweat needed to navigate the arduous journey that begins with the words “you have cancer.."
Bending our system toward a greater and deeper understanding of the profound human needs of our patients and their families is the first step in moving toward a system that aligns its priorities around what matters most. My years have taught me that the term "patient-centricity" is not a fashionable payer catchphrase; it is a deep, mission-driven pursuit that defines who we oncologists are and what we do.
Matthew Kemmann, Director of Strategic Planning & Analytics at University Hospitals Seidman Cancer Center (Cleveland): It's very difficult to overlook the impact of increasing preauthorization requirements and associated denials on cancer providers and their patients. There is no shortage of empirical and anecdotal evidence that quantifies the significant, and growing, financial and operational burden placed on oncologists and their staff by preauthorization and denials management processes.
More concerning are recent studies by the American Society of Clinical Oncology and American Society for Radiation Oncology, which suggest that a vast majority of time-sensitive medical and radiation oncology treatments are being adversely impacted by these processes. Since most denials are overturned on appeal, it might be easy to dismiss the impact on providers as the "cost of doing business," but the physical and emotional costs to patients warrant more attention and action.
As providers and payers struggle to adopt standardized processes, recent advocacy by the American Hospital Association and other groups has encouraged Congress to develop bipartisan legislation to mitigate this challenge. However, it remains unclear where this ranks as a legislative priority and what relief it might offer providers and patients.
Shiven Patel, MD, Assistant Professor of Oncology and Ambulatory Medical Director at the University of Utah School of Medicine and researcher at the Huntsman Cancer Institute (Salt Lake City): The greatest challenge for oncologists right now are the reimbursement models benchmarked by CMS, which do not take into account the great complexity and resources required to administer systemic therapies directed against cancer. This has made it even more challenging to deliver comprehensive care, specifically the ancillary services that are essential to our patients but unfunded by insurance.
Blase Polite, MD, Professor of Medicine at the University of Chicago Medicine's Comprehensive Cancer Center: One of the greatest reimbursement challenges oncologists face are the risks associated with reimbursement for very high-cost drugs. This includes retroactive denials from payers as well as pressures to give high-cost drugs in an inpatient setting where payment is usually bundled. Drugs represent nearly two-thirds of the total cost of cancer care, by far dominating the reimbursement discussion in oncology.
Derek Raghavan, MD, PhD, President of the Levine Cancer Institute and Chief of Clinical Network Development at Atrium Health (Charlotte, N.C.): This is a very complex healthcare environment, with the COVID-19 pandemic altering so many established patterns of care and patient flow. Patients are frightened and delaying care, leading to an unpredictable onslaught of advanced disease presentations. Thus, healthcare systems are struggling to cope with unexpected disease severity. This alters the balance of the value proposition, where screening and early detection of disease usually lead to better patient outcomes at lower cost.
That said, the prevarication of some health insurers and the devious tricks to avoid reimbursement even in these difficult times remains a key issue. The other challenge for reimbursement modeling is that nearly everything takes longer because of COVID-19 precautions and increased testing and documentation, ultimately becoming a major issue for fair reimbursement, irrespective of community-based or center of excellence practice.
Raghu Ram, MD, Vice President of Value-Based Care Optimization and Community Clinical Collaboration at Roswell Park Comprehensive Cancer Center (Buffalo, N.Y.): The main challenge for us and, I think, every other comprehensive cancer center, is exactly how to measure the value of the services that we are providing and how to translate that metric so it can be used as an effective basis for reimbursement.
Risk adjustment to address the complexity of care needed by the patients who come to a comprehensive cancer center is incredibly complex and challenging, especially in the era of precision diagnostics, immunotherapy and cellular therapy. We're still working with our payer partners to develop a model that embraces long-term survival as a main measure of value while also incentivizing advancements in the science of cancer treatment.