A new survey from the Association of Community Cancer Centers (ACCC) has identified pressures from multiple sources that threaten the growth of U.S. cancer centers. "Trending Now in Cancer Care," the ACCC's ninth annual survey on cancer center practice issues, found that centers are coping with pressures from payers, government, and industry.
The ACCC survey for 2018 was conducted in partnership with the Oncology Roundtable of the Advisory Board; the Advisory Board is a best-practices firm whose mission is to improve the performance of health care organizations. Some 205 respondents from 161 organizations participated in the 2018 survey, which was distributed by e-mail in July 2018.
Respondents (restricted to cancer center administrators and providers) reported their concerns against a background of remarkable advances in cancer care, the growing complexity and rising expense of care, tightening reimbursement requirements and uncertainties in health policy, and regulatory reform. The majority of respondents, 52 percent, were from non-teaching hospitals, while 23 percent were from teaching hospitals and 14 percent were from academic medical centers.
The top threats to program center growth identified by respondents were divided equally between reimbursement requirements from payers (48%) and the cost of new drugs and treatments (48%). Also identified as a major threat, by 40 percent of survey participants, are uncertainties in drug pricing reform policies.
On the survey, more than 80 percent of respondents replied that over the last 12 months the percentage of services requiring pre-authorization had increased. They also cited staffing challenges; more than half (60%) reported FTE vacancies for oncology nurses, nearly half (47%) reported having medical oncologist vacancies, and one in three (35%) reported vacancies for advanced practitioners.
Asked to name their concerns during a typical workday, survey respondents cited the following: 75 percent said workflow issues; 67 percent said a heavy workload; 46 percent said a lack of work-life balance; 29 percent said a lack of reward and/or recognition; 26 percent said a decreasing focus on patient care; and 22 percent said loss of control or flexibility at work.
"Despite the barriers and pressures programs face, survey results show continued progress in delivery of patient-centered cancer care," commented ACCC President Thomas A. Gallo, MS, MDA, Executive Director of the Virginia Cancer Institute in Richmond. "The data provided in this survey is a launchpad for ACCC through the year as we develop programs and resources to meet member needs and respond to changes in the health care environment," he added in a statement on the survey.
Personalized Medicine
While precision medicine rooted in genomic advances is widely considered the future of cancer care, survey respondents reported problems with such individually tailored tests and treatments.
On the issue of biomarker testing, for example, 68 percent of respondents said they were concerned about insurance coverage; 63 percent said they were concerned about payer reimbursement requirements; and 37 percent were concerned about insufficient protocols for collecting adequate tissue samples.
And while immunotherapy has been hailed as a major advance in treatment for those who respond, fully three-quarter of respondents (72%) said that cost and reimbursement are the biggest challenges to offering immunotherapy therapies to patients.
EHRs Challenges
As has been true on previous ACCC surveys, cancer center administrators and providers reported that they are still struggling with the demands of electronic health records (EHRs).
Although 69 percent of respondents reported that their EHRs either "significantly improved" or "somewhat improved" care coordination, nearly 70 percent said such electronic records have created increased work, making the workday longer for physicians and staff.
Some 10 percent of respondents said EHRs have "significantly worsened" and 49 percent said they have "somewhat worsened" provider well-being. And almost half (49%) said that EHRs have had a negative impact on provider-patient interactions. Fully one-quarter (26%) said EHRs have had a negative impact on physician and staff retention. Interoperability of EHRs continues to be of concern, with 19 percent of respondents reporting that their cancer center has not yet addressed the issue of interoperability. Only 3 percent of respondents reported "no interoperability challenges."
Cost Savings
On the new ACCC survey, respondents were asked to name the top five opportunities for cost savings in their cancer programs. Some 54 percent named clinical standardization (down from 63% in 2017); 54 percent named symptom management; 42 percent named drugs (down from 62% in 2017); 41 percent named care coordination; and 39 percent cited use of non-clinical staff: for example, financial advocates, and billing and coding specialists (up from 22% in 2017).
Respondents were also asked to name the biggest opportunities for return on investment. These were care coordination (45%); more sub-specialists, such as breast cancer specialists (44%); symptom management (36%); and screening services (30%).
Some 81 percent of cancer center programs have dedicated financial advocacy staff to help patients with the costs of their care. The high costs of care are a major concern for survey respondents.
Asked to what extent they are concerned about cancer patients refusing treatment because of financial worries, 41 percent of respondents reported that they were somewhat concerned, and 38 percent reported that they were very concerned. Only 4 percent said they were not at all concerned. Asked whether, during the past 12 months, a patient had refused treatment because of financial worries, 49 percent of respondents said yes, 19 percent said no, and 32 percent said they were unsure.
Both the American Cancer Society and ASCO have also identified so-called "financial toxicity" as a barrier to cancer care. Concern about the cost of cancer care was identified as a major issue in ASCO's report, "Clinical Cancer Advances 2018." In that report, 91 percent of Americans said the cost of cancer drugs is too high, and among those responsible for paying for a loved one's cancer treatment, 68 percent said they were concerned about cost.
According to the ASCO report, fully one in four Americans who have had direct experience with cancer took steps to reduce costs, steps that could reduce the effectiveness of their treatment. Specifically, 9 percent skipped doctors' appointments; 8 percent refused treatment; 8 percent postponed filling or did not fill prescriptions; and 7 percent cut pills in half.
Telehealth Growth
The new ACCC survey shows that telehealth is becoming more widely used by U.S. cancer centers.
The most popular services currently being provided via telehealth technology reported were genetic counseling (35%); oral chemotherapy adherence, education, and support (20%); symptom management consultations (19%); second opinions (18%); follow-up visits for patients in active treatment and survivorship visits (16%); and nutritional counseling and financial navigation (15%).
The six most popular telehealth applications cancer centers plan to provide in the next 2 years are survivorship visits (33%); genetic counseling (29%); oral chemotherapy education and support (28%); symptoms management consultations (28%); symptom monitoring and medication consultations (27%); and nutrition counseling, palliative care consultations, and financial navigation (24%).
But unanswered questions about telehealth remain, and survey respondents raised concerns about barriers to broader use of telehealth in cancer centers. Specifically, they named the following: reimbursement (70%); operational changes required, such as staffing or technological requirements (64%); provider reluctance (41%); the capital required to invest in telehealth technology (41%); and regulatory requirements (27%).
Survey respondents said a key reason for wanting to provide more telehealth services is lack of transportation for their patients. More than two-thirds of respondents (67%) said they partner with an organization to provide transportation for cancer patients, with another 37 percent reporting that they established their own transportation program to ensure that patients can get to the center for treatments. As previously reported in Oncology Times, living in rural areas and the inability to pay for transportation contribute to a growing U.S. socioeconomic divide in cancer mortality.
Looking Forward
Those answering the new ACCC survey reported that over the next 2 years they plan to provide a number of support services to their patients in addition to financial counseling and help with transportation, if they are already doing so, including an urgent symptom management clinic (38%); a survivorship clinic (31%); a symptom management phone triage center (26%); a high-risk clinic (21%); and palliative care services (15%).
Most cancer support services are generally unreimbursed, and survey respondents said they plan to pay for them first out of the center's operating budget, and second with funds raised by the center-for example, grants and corporate donations.
Peggy Eastman is a contributing writer.