Thursday, Dec 7, 2023

Policy Innovations as a Lever for Health Equity

Harlan Levine, M.D.President, Health Innovation and Policy, City of Hope


In partnership with a broad coalition, City of Hope charted a path to support cancer patients enrolled in California's Medicaid program, who, in some cases, experience outcomes worse than patients with no insurance at all. The California Cancer Care Equity Act (CCCEA) was passed to ensure that patients with certain complex cancers have the right to seek care at academic centers if their network cannot provide the appropriate level of care. In this article, we’ll discuss how City of Hope and other community partners leaned in to identify and define a problem, and then drove to a solution that can serve as a model for future policy reform.

Cancer Care is Different 

Cancer care is expensive, and mistreating patients adds to that expense, particularly in human costs. When patients with rare or complex cancers have access to care at a comprehensive cancer center, they often experience better outcomes at lower costs. Data show significant differences in outcomes, including survival, when a patient is seen an NCI-designated comprehensive cancer center versus non-academic settings.

The Cancer Care Is Different coalition, consisting of City of Hope, the American Cancer Society Cancer Action Network, the Leukemia & Lymphoma Society, Susan G. Komen, Be the Match, the Latino Cancer Institute and California Black Health Network, among others, is driven by the belief that, because cancer care is complex, we must safeguard access to expertise when it’s needed, providing the best chance of cure for every patient.  

In the last ten years, the field of oncology has undergone transformational change.  Advances in our understanding of genomics have spearheaded an overhaul in our approach to diagnosis, treatment and monitoring of cancer.  While many cancers are well managed in the community setting, it is important that patients have seamless access to academic centers when the patient is in need of cell-based therapies, emerging targeted treatment, complex surgery, multi-disciplinary or multi-modality treatments or a first-in-human clinical trial.  Today, our managed care programs often create barriers to such access, and this can lead to misdiagnoses and mistreatment that can often mean unnecessary exposure to toxic chemotherapy, suffering or avoidable death.

These outcomes can be avoided with effective policy. 

California Cancer Care Equity Act 

The California Cancer Care Equity Act (SB 987) expands access to specialized cancer care for Medi-Cal patients who receive a complex cancer diagnosis. This important bill, which went into effect Jan. 1, 2023, will benefit and save countless lives. SB 987 represents a critical first step in delivering on the promise of the California Cancer Patients Bill of Rights resolution, which recognizes that cancer patients should receive appropriate, timely and equitable access to expert cancer care. 

The CCCEA helps remove one set of obstacles that prevent access to innovative care for Medi-Cal beneficiaries — who represent approximately one-third of California’s population. At present, many patients on Medi-Cal experience inferior survival rates compared to patients on private insurance. 

In an age when new treatments such as CAR T cell therapies are improving health outcomes while demonstrating cost-effectiveness, CCCEA will increase access to the kind of cancer care any Californian would demand for a loved one fighting the disease.

This is an important first step in creating a more equitable cancer ecosystem that works better for patients and expands access to lifesaving, groundbreaking treatments for those from historically underserved communities.

Expanding Access to Optimal Cancer Care 

City of Hope looks forward to exploring opportunities to remove unnecessary barriers that keep additional populations of cancer patients from achieving improved cancer care outcomes, with an intent to elevate conversations surrounding narrow networks. 

One opportunity is Medicare Advantage plans, which frequently have narrow provider networks that do not include the research medical centers that provide access to clinical trials and the most advanced treatments. 

Sixty percent of Medicare Advantage plans do not include access to any of the 56 NCI-designated Comprehensive Cancer Centers. Medicare Advantage enrollees are only one fifth as likely to be treated for cancer at an NCI-designated center than people with traditional Medicare, and they are one third as likely to be treated at any academic medical center.

The implications of this disparity are significant.

For some complex procedures, Medicare Advantage cancer patients have higher mortality rates than patients with traditional Medicare. For example, Medicare Advantage patients who have surgery for pancreatic cancer are twice as likely to die in the month after surgery than those with traditional Medicare. Medicare Advantage patients with stomach and liver cancer are fifty percent more likely to die during the month after surgery. But the differences in outcomes are not limited to surgical rates alone.

When a network does not have the expertise to deliver advance therapies, a patient will be less likely to be referred for such therapy. In the case of a therapy like CAR T cell therapy, it can mean the difference between life and death-- CART T cell therapies have increased the success rates of treatment for certain leukemias and lymphomas by 50 to 80 percent.

The same pattern is found in clinical trials, which can involve highly promising drugs that won’t be available to the general public for years. If you are in many Medicare Advantage plans, and don’t have access to an academic center, you are far less likely to be enrolled into a clinical trial.

As part of its mission to expand access to optimal cancer care, City of Hope is advocating for policy changes to include Comprehensive Cancer Centers and other research centers in every Medicare Advantage provider network. The goal is not to lessen the role of the community oncologists, who remain a key pillar of cancer care, but to partner community oncology with academia,  establishing a modernized the definition of network adequacy.

Through policy innovations and partnerships such as these, progress can be made toward a healthier, more equitable future for all. 

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