National Comprehensive Cancer Network

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Commentary – Access to Cancer Care in the Era of Restricted Provider Networks

By Liz Danielson, Director, Payor Relations and Trish Goldsmith, Executive Vice President/Chief Operating Officer

There is broad consensus that the United States’ current health care system is deeply flawed and that trends in health care spending are unsustainable.  The recent health care reform bill (the Patient Protection and Affordable Care Act or PPACA) offers an opportunity to kick start changes that are badly needed.  Where substantial disagreement exists, of course, is where it’s always found:  in the details. We can all agree that it is essential to reduce ineffective care and costs; inefficient providers of care must be given reasons to become more efficient.  But how?

Among the ideas already gaining traction is the “restricted network” model that limits the physicians, hospitals and other providers included in the network to those that are viewed as less expensive; these models provide no out-of-network coverage.  Massachusetts recently enacted legislation that mandates insurers to offer at least one such network with a base premium that is at least 12 percent lower than the base premium for the insurer’s  most comparable non-restricted network products.  As noted in The Boston Globe (April 17, 2010),“Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals such as Massachusetts General and Brigham and Women’s — a once radical idea that is gaining traction as a way to control soaring health care costs.”

Large managed care organizations including Aetna, Cigna, WellPoint and UnitedHealthcare are already developing or offering this type of product (The New York Times, July 17, 2010). It is widely anticipated that large academic cancer centers will be excluded in these products as well.

While most hospitals and medical practices undoubtedly can find opportunities to be more efficient, academic cancer centers face greater challenges than others, for reasons including their responsibility for training tomorrow’s physicians and their commitment to conducting cutting edge research – investments that benefit society but are not fully funded by the government or other sources.

All purchasers of health plans, whether private or public, employers or individuals, as well as health insurance companies, should be looking for value for their premium dollars, not only lower costs.  While a majority of cancer care can be obtained in the community setting, an estimated 10-15 percent of patients with cancer should have the option of treatment at a major cancer center.  This includes:

• Individuals with uncommon and complex cancers such as brain tumors, sarcoma, head and neck cancers and others, which are infrequently seen and treated by most physicians.
• Individuals with cancers, such as lymphoma, that are difficult to diagnose and where accurate diagnosis is essential in determining the appropriate treatment.
• Individuals requiring complex surgeries where research has validated improved survival when surgery is performed at high volume centers by high volume surgeons.
• Individuals who require other complex treatment, such as a stem cell transplant, where special expertise and an experienced multidisciplinary team is essential.
• Individuals who want or need access to clinical trials that are not available in the community.

Lacking access to large academic cancer centers may be a life and death issue for those who fall into these categories.  What is the cost of not having access to large academic cancer centers?

If you’ve worked in the cancer field for any length of time like we have, you will have received many calls from friends and family members who have been diagnosed with cancer, or who have a loved one who has been diagnosed with cancer.  Their question is: “Where is the best place to go for treatment?”  They never ask: “Where is the least expensive place to go?” or “Where should I go that is in my provider network?”  Few people think about whether the best cancer centers are available through a health plan until the moment of need.  At that moment, they may find they don’t have access to physicians and hospitals that offer the best opportunity for survival.

The American public – through the National Institutes of Health and other agencies – has invested billions of dollars supporting academic cancer centers by funding research and the education of physicians, nurses and other health care professionals.  Excluding these medical centers from any health plan offering means that the benefits from these investments may, in the future, be unavailable to many people whose health plan offers only a restricted network.  Could you or a loved one be one of those individuals?