Policy Priority: Access

Network Adequacy

Intended to lower healthcare costs, narrow network plans limit patient access to advanced cancer care and result in burdensome travel times to access in-network providers, higher cost sharing for academic cancer centers, and out-of-network status for academic cancer centers. Network adequacy standards should assist health insurance companies with negotiating appropriate rates with all high quality, high value, providers to ensure patient access to appropriate care. In order to ensure networks provide adequate access to appropriate care for people with cancer, NCCN affirms that:

  • Academic cancer centers are skilled in serving patients with rare, complex, and advanced cancers and offer innovative therapies as well as access to clinical trials;
  • Network adequacy requirements should include guidance specific to cancer-related care, which tends to be multidisciplinary and often multisite, requiring close care coordination and adherence to established evidence-based guidelines to optimize outcomes in the highest quality and most cost-effective way; and
  • Network adequacy standards should require true adequacy of cancer specialist provider networks to ensure patient access to all necessary and clinically appropriate specialists according to evidence-based guidelines.

Pain Management

Pain is one of the most common symptoms associated with cancer and pain management is an essential part of oncologic care. In recent years, the rise of opioid addiction and overdose in the United States has led to increased scrutiny of opioid prescribing practices. In the management of cancer, multiple reports indicate that a patchwork of regulatory and coverage policies, intended to curb inappropriate opioid use, has led to significant barriers for many cancer patients when opioid use is clinically indicated for pain management. The NCCN Guidelines for Adult Cancer Pain advises that cancer pain can be well managed in the vast majority of patients with appropriate techniques, careful monitoring, individualization, and safe prescription medicines. In order to ensure that people with cancer have access to appropriate pain management while reducing the potential for harm from opioid addiction, NCCN affirms:

  • That it is important to ensure that opioids continue to be prescribed for patients for whom they are appropriate, and it is also essential to ensure that these drugs are prescribed carefully and appropriately to manage risk.
  • The Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain is not applicable or intended for people who suffer acute or chronic pain from conditions such as cancer. This was affirmed by the CDC in a 2018 memo and within the updated CDC Guideline released in 2022. Clinical practice guidelines offer an important tool to inform policy and practice for these special populations. State and federal regulatory and legislative policies, as well as coverage policies addressing opioids, should utilize population-specific clinical practice guidelines to ensure appropriate access as well as risk management.

Innovative Therapies

Cancer care is a field marked by multidisciplinary care and constant innovation, with rapid advancements in technologies and therapeutic interventions. Current reimbursement rates for novel, high-cost, therapies are hundreds of thousands of dollars below the actual cost per patient. In addition to the high acquisition cost, the administration of treatments like CAR T-cell therapy can be accompanied by significant toxicities including cytokine release syndrome (CRS), neurotoxicity, and prolonged cytopenia. The intensive and specialized services required to manage these toxicities adds significant additional cost, further compounding reimbursement challenges. Government reimbursement models must be modernized to match new methods of treatment. In order to preserve patient access to cutting-edge cancer management techniques, NCCN affirms that:

  • Policies should facilitate the availability of innovation whenever it is supported by the highest-available level of evidence;
  • NCCN supports legislative, regulatory, and coverage policies that advance the coverage of innovative therapies when clinically appropriate as established by nationally-recognized guidelines; and
  • Commercial and public payers must establish payment policies that provide adequate reimbursement so as to ensure providers and patients are not saddled with a disproportionate share of the financial responsibility.