Policy Priority: Ensure patient accessibility to guideline-supported care

Investment in Specialty Services

Studies have shown that academic cancer centers provide superior care for patients with rare, complex, or advanced cancers.  Academic cancer centers provide comprehensive specialty care that is uniquely distinct from care in traditional physician office settings. Additionally, recent studies have shown academic cancer centers to have superior outcomes even in cancers considered common or high-volume. In order to ensure that people with cancer receive treatment at appropriate facilities, NCCN affirms that:

  • Payment reductions to off-campus accepted hospital based providers inadvertently penalize providers for providing high quality, comprehensive services that are typically available and provided at hospital-based facilities. Proposals to significantly decrease resources within the academic cancer center clinical system will likely result in significant barriers to patient access to comprehensive high-quality cancer care. This is particularly concerning for patients with complex, rare, or advanced cancers.
  • Cancer care is a field marked by multidisciplinary care and constant innovation, requiring adequate reimbursement to protect technological and scientific advancements in care delivery.

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. 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.

Patient Access to Care Planning and Coordination Services

As of January 2016, there were more than 15.5 million living Americans with a history of cancer, a number that is estimated to grow to more than 20 million by 2026. NCCN has long recognized the importance of patient/provider communication and education in cancer care.  Over the last two decades, NCCN has developed a collection of resources and programs to support and educate stakeholders across the oncology spectrum, including physicians, researchers, nurses, policymakers, industry, payers, patients, and patient advocates.  NCCN publishes a library of NCCN Guidelines for Patients® based directly on the information found in the NCCN Guidelines to provide patients with the same information their doctors’ use, but in easier-to-understand language.  Additionally, the NCCN Guidelines for Survivorship are designed to provide a framework for the general survivorship care plus management for any potential long-term and/or late effects of cancer and its treatment that survivors may experience. In order to ensure optimal survivorship care for people with a history of cancer, NCCN affirms that:

  • High-quality cancer care is only possible when patients are appropriately informed of their treatment options and engaged in a shared decision-making process with their healthcare provider. NCCN supports legislative, regulatory, and coverage policy that advances the utilization of care management plans and patient navigation to advance the delivery of patient-centered care in oncology.
  • Cancer care planning and coordination services are a critical component of high-quality cancer care. As such, these services should be supported and expanded to improve patient/physician communication, patient-centered care and shared decision making.

Patient Access to Clinical Trials

Years after the passage of the 21st Century Cures act, clinical trials still struggle with successful recruitment and retention of diverse patient populations. A 2019 study found that of the 230 clinical trials leading to FDA oncology drug approvals over the past decade, race was reported in only 145 (63%) trials. Of the studies that did report, people of color were significantly underrepresented. Additionally, the majority of clinical trials are restricted to adults between the ages of 18 and 64, resulting in an under-representation by children and older adults. In order to enable and encourage greater participation in clinical trials to further knowledge and extend access to the benefits from this mode of treatment, NCCN affirms that:

  • Access to life-saving therapies for Medicaid enrollees requires the coverage of routine patient costs associated with participation in qualifying clinical trials. Routine costs include the non-experimental costs of treating a patient who is participating in a clinical trial, such as the cost of physician visits or laboratory tests.
  • The best management for any patient with cancer is within a clinical trial. Clinical trials offer patients access to the most current cancer care, treatment by experts, carefully monitored results tracking, and the ability to help other patients with cancer.

Patient Access to 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.