Coverage in Health Equity: December 2023

Moving the Needle on Health Equity Demands Practice-Level Commitments

To move beyond discussion of why health care disparities exist, oncology practices must build health equity into the basic business model, not regard it as something to “get to” in everyone’s spare time. Having a point person who is accountable for the practice’s health equity goals makes sense, but every person in the practice plays a role, according to panelists who took part in an October 24, 2023, discussion at the Community Oncology Alliance (COA) Payer Exchange Summit in Reston, Virginia.

The panel “How Are We Moving the Needle on Health Equity?” featured moderator Alti Rahman, MHA/MBA, CSSBB, who in July became chief strategy and innovation officer for the American Oncology Network. Panelists were Ricky Martin III, MD, MPH, medical director for health equity and community engagement, Tennessee Oncology; and Ann Sweeney, MA, CCMP, senior director, quality programs and process improvement, Blue Ridge Cancer Center, based in Roanoke, Virginia.

Factors in Health Disparities

Rahman started the discussion with an overview of the factors that contribute to disparities in health outcomes:

• Social and community factors, which include underlying issues of discrimination, racism, poverty, and personal support systems
• Health care access, an umbrella that includes whether individuals have adequate insurance coverage “as well as the notion of health care deserts or unavailability of services”
• Environmental conditions, which examine how populations live and include social determinants of health (SDOH), such as adequate housing or food
• Genetic factors, including whether payers offer adequate coverage to learn what might be driving cancer

Both federal programs and commercial plans have evolved around these factors, Rahman said, and today oncologists feel the impact of consolidation among primary care providers, as this has effects on CMS’ accountable care organization (ACO) models. From the original ACO model, which had 232 participants, the new ACO REACH model emerged with a focus on health equity; this model covers 2 million lives, he said.¹ Newer risk-sharing contracts have greater transparency, and newer CMS frameworks for hospitals put more emphasis on data collection, analysis, and quality improvement.

In addition, he said, CMS is focused on not just “drilling down on social drivers of health,” but also “screening for positive rates as well.”

“This is a movement in the area of the hospital/health system landscape,” he said. The trend is to move the examination of health equity down from the national perspective to a local one, so that each community can think through its own solution.

“At the individual practice level, aligning with community-based organizations has been something that we’ve done all along. But now, how does a payer—or [multiple] commercial payers—think through it also?” he asked. There’s also a focus on where Medicaid fits in.

Organizations such as the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) are also creating frameworks, Rahman said; NCCN created the Health Equity Scorecard, and ASCO has created multiple resources and the Quality Oncology Practice Initiative (QOPI) certification.²

Tying Healthy Days to Cost Savings

When Rahman was administrator at Oncology Consultants, based in Houston, Texas, the practice launched its HOPE Initiative (Holistic Oncology Patient Equity).³ The initiative featured an electronic screening tool to measure “healthy days,” using a questionnaire to ask patients about physical and mental health effects over the previous 30 days. The CDC-validated tool has been used by Humana and others to track population health effects over time,⁴ and Oncology Consultants was able to track improvement among both its Black and Vietnamese patient populations, which are prevalent in the Houston area, Rahman said.

When Oncology Consultants tracked how well it was doing in meeting patients’ SDOH needs, Rahman said, it recorded a very high rate of SDOH needs fulfilled (97.8%), “which correlated to an increase in healthy days.” COA, he said, is working through the cost-of-care implications of these findings. In 2024, through a partnership with Gilead Oncology, COA will create a workshop to help practices implement these systems in their own practices.

When Resources Are Scarce, Practices Must Fill the Void

Sweeney said Blue Ridge’s challenge went well beyond identifying sources of inequity—the big question was what to do about them. In going through the ASCO’s QOPI certification, the practice had to identify ways to address SDOH issues its patients presented.

“We had navigators, social workers that were working to identify barriers to care or connecting patients [with] resources, but the inherent flaw with these plans—and to throw in another really difficult layer—is that there are not centralized resources in Roanoke, Virginia,” she said, or anywhere else in the smaller cities that Blue Ridge serves.

“So, we were dually faced with, first, we don’t have the support services without mass variation, and we don’t have resources for our patients, and, second, we’re coming out of COVID[-19],” Sweeney said. “And a lot of organizations that did help our cancer patients in the past had shut down and were not coming back.”

The question became, “Where do we need to start?” Sweeney outlined the steps taken:

• She began by researching the population in southwest Virginia; she gained more understanding of the socioeconomic data of the area—what data she had and what should be added.
• Blue Ridge invested in health equity administrators; these staff “were not only doing some of the strategic work, but they were really managing the patient connection to resources,” she said.
• Next came communicating priorities to all physicians and staff. “We realized that we needed to do a lot of education,” Sweeney said. What is the different between SDOH and health-related social needs? What is unconscious bias, and why do health inequities exist? And how does unconscious bias relate to what happens when patients arrive at the clinic?
• The result: Sweeney said Blue Ridge moved to start a diversity, equity, and inclusion affinity group.

The practice now has a health equity administrator, an overhauled referral process that connects patients to resources, and a system to measure how well this process is working. “We went from zero to all this in a year and a half. So, it’s doable,” Sweeney said. “But you have to commit, and you have to realize that all of us have to do our part. This can’t just be a requirement from a payer, [such as] CMS saying, ‘Do I have to have a health equity strategy?’ ”

Even though payers and employers in the region also have a stake in health equity, it will fall on the practice to coordinate these resources. “It’s really hard. But if we all do our piece, it will eventually fit together,” Sweeney said. “And it will be the right thing for our community members and patients.”

Needs Differ With Each Area, Each Patient

Martin described what he called his “journey” in working on health equity, which began with his work in Nashville-area clinics that included many disenfranchised patients—including the homeless and those in prison. When patients who have significant social needs “become the rule and not the exception in your practice, these barriers become much more obvious.”

So, Martin said, he learned to develop pathways for these patients just by listening to their ideas. There were plenty of challenges, not the least of which was Tennessee’s failure to expand Medicaid.

Arriving at Tennessee Oncology has allowed Martin to execute some of his ideas for patients who are uninsured or underinsured. Having colleagues who are deeply knowledgeable about value-based care gives Martin opportunities to share his ideas, “and they can fill in that economics piece,” he said. “But my expertise is really thinking from that lens of the underinsured, historically disenfranchised patient–centered experience and say, ‘How is this going?’ Because we keep trying to make a lot of these tools and instruments and find the right metrics. But at the end of the day, no one is really factoring, ‘Is this going to work for the patient?’ That’s where I come in, and it’s been a good model so far.”

Martin emphasized that although collecting patient information is important—and best practices must be followed—physicians should be extremely cautious about assuming what those data reveal based on a person’s racial or ethnic category.

“Hopefully, this should be obvious to everybody—the needs of a Black individual in south Chicago are not the same as the needs of a Black individual in Appalachian rural Tennessee,” he said. “The usability of that information to make a difference in the patient’s care experience can be incredibly local and regional, based not only on the patient demographics but also what exists on the other side of the health care system within that community.”

Payers, or other stakeholders, might ask what the return on investment (ROI) is to collect data or operate a health equity initiative. But that ROI can be in the eye of the beholder, and the most important stakeholder is the patient, he said, and it may take time for the fruits of an effort to be seen.

Another key to moving the needle, Martin said, is ensuring that patients can be treated or served by staff from their own community. It’s essential, he said, “that you know that the people collecting the information are people like you, and that they have your back. I think that’s a really powerful message to have.” Practices and companies must also have internal checks and balances to ensure good stewardship of information.

Despite the reality of workforce shortages, Martin said, the long-term goal of improving health equity could mean this is a good time to reshape a staff in a way that looks like the community it serves. Reaching students who are not yet licensed and getting them involved opens doors, he said.

The future workforce can be reached, he said, “by doing community engagement events around early detection and screening for some cancers, and by listening.… It’s showing the people who we hope to hire in the future, that if I work for this company, I would be able to make a difference in my community. And it’s also shown the communities, ‘Oh, they’ve invested in hiring people that are from my community to help me out.’ ”

References

1. ACO REACH: fact vs fiction. National Association of ACOs. Accessed November 20, 2023. http://.www.naacos.com/aco-reach—fact-vs—fiction
2. QOPI certification program. American Society for Clinical Oncology. Accessed November 20, 2023. https://practice.asco.org/quality-improvement/quality-programs/qopi-certification-program
3. HOPE Initiative. Oncology Consultants. Accessed November 20, 2023. https://www.oncologyconsultants.com/hope-initiative
4. CDC’s healthy days measures used in America’s Health Rankings. CDC. Updated October 31, 2018. Accessed November 20, 2023. https://www.cdc.gov/emotional-wellbeing/features/healthy-days.htm

Saira Jan, PharmD, MS, Explains Oncology Home Infusion Pilot Program

Saira Jan, PharmD, MS, of Horizon Blue Cross Blue Shield of New Jersey provided an overview of a collaborative oncology therapeutics home infusion pilot program with Rutgers Cancer Institute of New Jersey and RWJBarnabas Health. She explored the program and its findings during the Academy of Managed Care Pharmacy (AMCP) Nexus session, “Implementation of a Novel Oncology Home Infusion Model.”

At Horizon Blue Cross Blue Shield of New Jersey, Jan is the vice president and chief pharmacy officer. She is also professor emerita at Rutgers University’s Ernest Mario School of Pharmacy. Jan spoke with Evidence-Based Oncology (EBO) during AMCP Nexus, held October 16 to 19, 2023, in Orlando, Florida.

EBO: Could you please provide an overview of the oncology therapeutics home infusion pilot program?

Jan: The oncology pilot that we started in 2020 was something that we always wanted to do, but oncology home infusion has always been very controversial. When the pandemic happened, that really instigated for us to think differently in how the delivery systems for oncology drugs had to change, because the members were unable to go to the hospitals for infusions. It was a big gap, not getting an infusion for chemotherapy, and having the pandemic leading to that gap was a tremendous opportunity for us to start thinking differently.

We started working with our partner, which was Robert Wood Johnson/Rutgers Cancer Institute of New Jersey. The director of the cancer institute, Dr Libutti [Steven K. Libutti, MD, FACS], and I basically connected, and I said to him that we really want to do this. It’s sad that the pandemic instigated this kind of a project, but this was, I would always say, a positive of the pandemic, which was a negative thing.

Dr Libutti really bought into the idea. I wanted this project to be a collaboration with a provider. Oncology is a condition, and the drugs that are utilized have to be monitored; there are a lot of safety concerns. So, a provider partnership is the key to the success of this pilot. The whole premise at that point was to really improve access for the members who needed the treatment and to understand what the logistics were, what the operational challenges were, and what pieces needed to be put together to really accommodate everything from a safety perspective, from a member perspective, from a monitoring perspective in this pilot.

The pandemic [initiated] this, but then, we had to really do it in a way that had all aspects of management covered, not only from a hospital perspective, infusion perspective, but also from a benefit design perspective, from a payer perspective. So, we established a few working groups from a medical policy perspective, from an operational perspective, to really understand when the member comes in, how will that work? Will they get the first infusion in the hospital? What the process would be.

We were lucky that Robert Wood Johnson had a home infusion company, and that was another group that had to be skilled to really infuse this, establishing the process of monitoring remotely when the nurse went in the patient’s home to infuse the chemotherapy, any side effect profile.

One key component of this pilot was not only to establish the operation and execution of home infusion but also understand the member feedback, the provider feedback. As we went through the pilot, we infused the feedback as we were developing the pilot throughout. I think that was a big focus: to improve quality, improve access, improve the convenience and member experience in chemotherapy, and then use this opportunity to introduce an innovative model of delivery for oncology. Because remember that a lot of drugs that are infused in the hospital are now infused in patients’ homes or infusion centers. Traditionally, oncology has been limited to hospitals. This was a great opportunity for us to show that it could be done outside the hospital.

Think of members who have cancer; there are a lot of side effects. I’ve had stories from patients with chemotherapy throat, first of all, drive a couple of hours, or an hour, to the institute or a hospital to get the infusion and then on the way back, they’re throwing up, lots of nausea. So, if you can simplify that and have this infused in a patient’s home, or an infusion center close to the patient, that would really take away the negative aspect of these adverse events. That was also an area that I think helped us to really move forward with this.

Racial Discrimination in Cancer Care Has Long-Term Impact on Patients, Study Shows

A discouraging trend of racial discrimination in cancer care was identified in an in-depth analysis published in The Journal of the National Cancer Institute.¹ Racial disparities in health care have long been a topic of concern, with recent research shedding light on the impact of racial discrimination on Black patients with cancer.

The study, conducted from May 2019 to March 2020, aimed to explore how experiences of racial discrimination within the health care setting manifest for Black patients with cancer and contribute to disparities in cancer care.

The research employed a qualitative analysis approach, utilizing semi-structured, in-depth interviews with 18 Black cancer survivors not currently on active treatment. The participants, ranging in age from 29 to 88 years, provided valuable insights into their encounters with racial discrimination in the health care system. All interviews were audio recorded, professionally transcribed, and analyzed using Dedoose software to identify major themes and subthemes.

The findings revealed that most participants reported experiencing racial discrimination when seeking cancer care. The sources of discrimination were diverse, encompassing interactions with health care staff, medical assistants, front desk personnel, and health insurance administrators. Overt racial discrimination was identified, rooted in racial stereotypes and often manifested through verbal insults. Some physicians were reported using phrases such as, “you people,” exacerbating the degradation of the patient-provider relationship.

“When instances of experiencing racial discrimination occurred, patients expressed these experiences were associated with negative emotions long after the experience concluded and impacted the ability of the health care system to demonstrate trustworthiness and limited the options available to patients to make informed decisions about care,” the investigators wrote.

“Instances of racial discrimination also resulted in patients feeling their voices were dismissed and increased the psychological burden and time toxicity with receiving care,” they continued. “The silencing of Black cancer patient voices impacted patients’ health-care utilization and had implications for their physical health.”

The study aligns with prior research indicating that exposure to racial discrimination is linked to psychological distress; negative patient experiences; and lower levels of trust, satisfaction, and communication in health services. For Black patients with cancer, such exposure is associated with fewer physician office visits and challenges in adhering to cancer screening guidelines, leading to underutilization and disengagement from health care services.

Most medical interactions for Black patients occur in racially discordant settings, where the patient is Black and the physician is not, investigators noted. Such interactions are characterized by less patient-centered communication and lower levels of positive affect, potentially stemming from implicit biases present among health care providers.

Quality of care—including time spent with providers, shared decision-making, emotional support, and effective communication—emerged as a significant predictor of Black cancer survivors’ self-reported health outcomes. The study underscored the impact of patient-provider relationships on health outcomes, suggesting that exposure to racial discrimination may worsen health disparities by degrading these relationships.

The study advocated for a biopsychosocial approach in future research on social determinants of health, emphasizing the importance of considering individual and health care system–level factors specific to Black patients in addressing cancer care disparities. The authors emphasized the need for partnerships with communities to expand research participation and enhance access to high-quality cancer prevention, early detection, and treatment.

Additionally, they called for accountability, urging the development of routine methods for patients to provide feedback on racial discrimination experiences and transparency to identify strategic improvements in health care organizations. 

Reference

1. Garrett E, Ma C, Ochoa-Dominguez CY, et al. Black cancer patients navigating a healthcare system of racial discrimination. J Natl Cancer Inst. 2023;djad208. doi:10.1093/jnci/djad208

Miriam J. Atkins, MD, FACP, Discusses Challenges in Recruiting, Clinical Trials

Miriam J. Atkins, MD, FACP, president of the Community Oncology Alliance (COA) and practicing partner at AO Multispecialty Clinic in Augusta, Georgia, highlights the critical challenge of the physician and nurse shortage in the United States. She discussesthe lack of guidance for health care professionals regarding job offers—and obstacles in improving minority enrollment in clinical trials, including strict inclusion/exclusion criteria that often exclude real-world patients with multiple health issues. Atkins spoke with Evidence-Based Oncology (EBO) during the 2023 COA Payer Exchange Summit, held October 23 and 24 in Reston, Virginia.

EBO: Can you speak to what you believe is the biggest challenge the field of oncology is facing today?

Atkins: The biggest challenge we face right now is physician recruitment and nurse recruitment. Because if we don’t have physicians or nurses, we can’t take care of any patients. So that’s a huge challenge. Right now, we’re working on strategies for that. There’s a shortage of doctors in the United States. So, I don’t know.... We’ll need help from all levels to work on that particular issue.

Then I have some people who are getting out of nursing and people finishing fellowship. They’re getting pulled by hospitals, pulled by academic centers, pulled by private groups. They don’t know what to do, and no one really shows them all the opportunities. I don’t know about nursing, but physicians, when you’re training, you’re focusing on patient care. No one tells you how to navigate the job offers. And I think part of that is intentional, because academic centers want to keep all the doctors there. But there are enough patients for everybody, and each one of us needs everyone else.

EBO: What are some potential solutions to improving minority enrollment in clinical trials?

Atkins: One huge way to improve minority enrollment in clinical trials is to keep practices in the community, as I mentioned. Many of my patients are in rural areas. They know me, they trust me, they don’t want to go to a big academic center. One other obstacle [is] the inclusion/exclusion criteria for these trials. The real patients are the ones that come in with kidney disease, diabetes, hypertension, a lot of other issues, and many of those patients don’t qualify for clinical trials.

They have certain things. For instance, you have to have a certain creatinine clearance. They may have too many issues that make them not qualify for a trial. Because the flip side of a clinical trial is, if a patient dies or gets very sick on a clinical trial, it may not be related to trial or the drugs, but the company has to prove that the patients were not harmed by the trial. That’s why the inclusion/exclusion criteria are so strict.