Access to Cancer Care in the Era of Restricted Provider Networks

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There is broad consensus that the United States' current health care system is deeply flawed with trends in spending that are unsustainable. The recent health care reform bill (Patient Protection and Affordable Care Act or PPACA) offers an opportunity for badly needed changes. Where substantial disagreement exists, of course, is where it's always found: in the details. We can agree on the need to reduce ineffective care and costs and give inefficient providers reasons to become more efficient. But how?Among the ideas gaining ground is a “restricted network” model that limits the physicians, hospitals, and other providers in the network to those viewed as less expensive, with no out-of-network coverage. Massachusetts recently enacted legislation that mandates insurers to offer at least 1 such network with a base premium at least 12% lower than that of 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...—a once radical idea that is gaining traction as a way to control soaring health care costs.” Large managed care organizations 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 also be excluded in this model.Although most hospitals and practices can undoubtedly find opportunities for efficiency, academic cancer centers face greater challenges, for reasons that include responsibility for training and commitment...

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

Among the ideas gaining ground is a “restricted network” model that limits the physicians, hospitals, and other providers in the network to those viewed as less expensive, with no out-of-network coverage. Massachusetts recently enacted legislation that mandates insurers to offer at least 1 such network with a base premium at least 12% lower than that of 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...—a once radical idea that is gaining traction as a way to control soaring health care costs.” Large managed care organizations 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 also be excluded in this model.

Although most hospitals and practices can undoubtedly find opportunities for efficiency, academic cancer centers face greater challenges, for reasons that include responsibility for training and commitment to cutting edge research, which benefit society but are not fully funded by the government or other sources.

Purchasers of health plans and health insurance companies should be looking for value for their premium dollars, not only lower costs. Most cancer care can be obtained in the community, but an estimated 10% to 15% of cancer patients should have the option of treatment at a major cancer center. This includes individuals:

  • With uncommon and complex cancers such as brain tumors and sarcoma that are infrequently treated by most physicians;
  • With cancers, such as lymphoma, that are difficult to diagnose and for which accurate diagnosis is essential in determining appropriate treatment;
  • Who need complex surgeries for which research has shown improved survival at high-volume centers by high-volume surgeons;
  • Who require other complex treatment, such as a stem cell transplant, for which special expertise and an experienced multidisciplinary team are essential;
  • Who want or need access to clinical trials not available in the community.

Access to large academic cancer centers may be a life and death issue for people in these categories. What is the cost of not having access to large academic cancer centers?

Clinicians in the cancer field have probably received calls from friends and family with cancer or from a loved one with cancer. They ask, “where is the best place to go for treatment?” not, “where is the least expensive place?” Few people think about whether the best cancer centers are available through a health plan until they need one. Then they may find they don't have access to physicians and hospitals that offer the best opportunity for survival.

The American public—through NIH and other agencies—has invested billions of dollars in academic cancer centers by funding research and education. Excluding these centers from any health plan means that the benefits from these investments may, in the future, be unavailable to some people. Could you or a loved one be one of them?

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of the NCCN.

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Elizabeth Danielson, MHA, is Director of Payor Relations at NCCN. She is responsible for developing, maintaining, and expanding working relationships between NCCN and managed care payor organizations. She is also responsible for the development and implementation of clinical training programs for payor case managers, medical directors, and others within these organizations.

Ms. Danielson has over 20 years of experience in the health care industry. Prior to NCCN, Ms. Danielson was Director of Cancer Programs at OptumHealth, a UnitedHealth Group Company, and before that, she was Administrative Director of the Blood and Marrow Transplant Program at the University of Minnesota.

Ms. Danielson earned her Masters of Healthcare Administration from the University of Minnesota.

Patricia J. Goldsmith is Executive Vice President/Chief Operating Officer at NCCN. In addition to the overall operations of NCCN, she is responsible for public policy initiatives at the Federal level and national initiatives related to payors and employers, including education. Ms. Goldsmith is also responsible for the NCCN Foundation, the philanthropic affiliate of NCCN.

Ms. Goldsmith formerly served as Vice President for Institutional Development, Public Affairs and Marketing at the H. Lee Moffitt Cancer Center & Research Institute. Before joining Moffitt, she developed and directed all managed care activities for the University of South Florida College of Medicine.

Ms. Goldsmith has studied at the Pennsylvania State University, the University of Missouri Bloch School of Business, and the Harvard School of Public Health.

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