Understanding the Challenges of Rural Cancer Care

Paris, Texas, with a population of about 25,000, is a long way in both miles and culture from Detroit, Michigan, where Sucharu “Chris” Prakash, MD, completed a fellowship in oncology and hematology. The city near the Red River that forms Texas’ boundary with Oklahoma offered an easier pace of life, friendly people, and a good place to raise a family, so 20 years ago Prakash and his wife made it their destination.

Prakash joined the Paris office of Texas Oncology, which serves patients across Texas’ Northeast corner, as well as some from Oklahoma. Now the area medical director, Prakash is passionate about bringing better care to his patients, and he serves on state and national-level committees to address the challenges of rural health care, including the American Society of Clinical Oncology’s Rural Cancer Care Task Force.¹

Rural health care delivery faces many challenges—from logistics, to finances, to keeping abreast of the scientific revolution in cancer care. Prakash points out that 60 million people, or about 19% of the US population, live in areas considered rural based on the Census Bureau’s definition, and that’s too many people too ignore.²

From his vantage point, he sees the many disparities among rural patients—the residents are older, with less education and income than their urban counterparts. When cancer occurs, the outcomes are generally worse.³ “They are diagnosed later,” so mortality is higher, he said. “Access to care is a major issue—that impacts screening and treatment. There are major barriers to insurance coverage and transportation.”

And, within the population are pockets that are particularly high risk: Native Americans, for example, have above average rates of alcohol abuse and higher rates of obesity.⁴ Veterans often cannot travel long distances to the nearest VA center for care.⁵

ASCO Weighs In on Rural Care
Work by the ASCO task force that Prakash joined in 2019 led to a report in June 2020,⁶ “Closing the Rural Cancer Gap: Three Institutional Approaches,” which identified the same disparities that Prakash sees every day, and more:

• While death rate from cancer are have fallen in both rural and urban areas, they are falling more slowly in rural areas.
• Rural patients have worse health outcomes in survivorship than their counterparts elsewhere, and this is especially true in the South, Appalachia, in tribal communities, and along the US-Mexico border.

• Rural patients are diagnosed later and less likely to receive stand-of-care treatment, follow-up or supportive services than patients in metropolitan areas.⁶

In addition, the ASCO report highlighted the challenge of geography is connecting patients with providers. While the percentage of oncologists in rural counties has expanded somewhat since 2014, data from 2019 show that 12% to 15% of oncologists work in rural settings, and about 20% of rural Americans live more than 60 miles from an oncologist.

“These higher percentages of oncologists practicing in rural areas, however, remain smaller than the share of US population residing there,” the report said.⁶

Gaps in Coverage and Financial Burdens
A major challenge, for both patients and providers, is insurance coverage and reimbursement. The Affordable Care Act (ACA), passed in 2010, was designed with the idea that Medicaid expansion would reach every household with incomes up to 138% of the poverty level. When the Supreme Court allowed states to decide whether or not to expand Medicaid, only half did in 2014, and 12 still have not as of October 1, 2020—including Texas.⁷ In states with Medicaid expansion, safety-net hospitals saw large drops in uncompensated care, but this was not so in non-expansion states^.8 Over the past decade, the closure of rural hospitals has been a story across the South⁹—and Northeast Texas has been hit especially hard, according to data from the University of North Carolina.¹⁰

Even when patients have Medicaid, it might not be enough. Depending on where patients live, if reimbursements are too low, not all doctors will accept this form of coverage.¹¹

Prakash sees these effects at the individual patient level, as well as the snowball effect that lack of coverage creates across the health system. Many families do not qualify for the tax credit that would allow them to buy coverage on the ACA exchanges, but either they cannot afford coverage, or they do not get it through an employer. “This lack coverage limits access,” he said. “They cannot get their basic screenings.”

When these patients are eventually diagnosed with cancer, providers must figure out how to absorb the costs, whether it’s through foundation help or patient assistance programs. Add in pressures from the 340B program and pharmacy benefit managers, and the situation can make it hard to attract the best talent, despite the good quality of life in the area. “The hospital is struggling to recruit, because everyone is aware of the problem,” he said.

Clinical Trial Participation
Historically, fewer patients from rural areas have taken part in clinical trials because they lived too far from academic centers.⁶ Being part of the Texas Oncology/US Oncology network has allowed Prakash to enroll his patients in clinical trials, and he finds them eager to participate. Rural patients, he said, “are tough and smart and highly adaptable—they reach down and gather strength. If they trust in God, they trust their physician,” he said.

Willingness on the patients’ part is only part of the equation. Trials need enough patients to support a research nurse, for example. Prakash said that ASCO recognizes the inequity that rural patients have experienced, and leaders have worked with rural providers to ease eligibility criteria and protocol design, so that rural patients can participate.

Rule Changes at CMS
CMS has experimented with rural health care models, but past efforts were limited to certain states. In August, as part of an effort called “Rethinking Rural Health,” the agency updated payment rules under the Inpatient Prospective Payment System (IPPS) to take effect for fiscal year 2020 (October 1, 2020), which officials said were designed with rural providers in mind.⁷ Although not specific to cancer care, the rule changes purport to address financial disadvantages that rural providers experience. And CMS then launched a payment model, called CHART, that addresses a long-standing complaint about the definition of “originating site” in telehealth, which had been a barrier for providers.

The IPPS rules changes are designed to:

• address wage index disparities by improving the accuracy of the calculation, and change the way the “rural floor” is calculated;
• increase the wage index for hospitals below the 25th percentile; and
• implement a required increase for hospitals taking part in a quality reporting program.⁷

With CHART, which stands for Community Health Access and Rural Transformation, CMS will provide funding to support new payment models, regulatory flexibility, and technology support to implement value-based capitated payment models that will allow an outpatient department or emergency room to be reimbursed as if they were a hospital.⁸

Telehealth and Staying Connected
The latest game changer has been the coronavirus disease 2019 (COVID-19). The pandemic has opened the door to telehealth on a scale not seen previously. Not every visit is appropriate for telehealth, as some patients still use a flip phone or want to see their doctor in person. But like many others, Prakash believes there’s no going back, and CMS has proposed making some aspects of the telehealth rule change permanent.⁹

Telehealth is poised to have “a profound impact,” beyond patient care and research, he said, because it offers possibilities for provider education and training for rural physicians, to “reduce the isolation, especially for early career oncologists.”

He sees virtual training as a tool to ensure there is better mentorship and support, and opportunities for young oncologists to more fully participate in major scientific meetings when they simply cannot take time off.

Long term, Prakash sees a need for development of the oncology work force in rural areas; this will require regulatory relief to improve the clinical trial staff and provide the psychological, nutrition, and support services that patients should expect. Meeting the needs of patients who often cannot afford their care is not easy, he said. “It is challenging. They need someone who is dedicated.”

But spending time with each patient, and learning their social and psychological needs has its benefits, too. “You do make a difference in the community. And people appreciate what you do.”

References
1. Dr. Chris Prakash joins national rural cancer care task force. Texas
Oncology website. Published October 21, 2019. Accessed September 27,
2020. https://www.texasoncology.com/who-we-re/news/2019/cancercare-
task-force.
2. United States Census Bureau. Rural America. October 1, 2020. https://
gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=
7a41374f6b03456e9d138cb014711e01.
3. Henley SJ, Anderson RN, Thomas CC, et al: Invasive cancer incidence,
2004–2013, and deaths, 2006–2015, in nonmetropolitan and metropolitan
counties — United States. MMWR Surveill Summ 2017;66(14);1–
13. DOI: http://dx.doi.org/10.15585/mmwr.ss6614a1
4. Risk of alcohol use among Native Americans. American Addiction
Centers. https://americanaddictioncenters.org/alcoholism-treatment/
native-americans. Updated January 2, 2020. Accessed
September 29, 2020.
5. VA updates veterans’ choice program to consider driving distance.
News release. April 14, 2015. Accessed September 29, 2020. https://
lamalfa.house.gov/media-center/press-releases/va-updates-veterans-
choice-program-to-consider-driving-distance
6. Levit LA, Byatt L, Lyss AP, et al. Closing the rural cancer care gap: three institutional approaches. J Oncol Pract. 2020;16(7):422-430. doi: 10.1200/OP.20.00174
7. Trump administration finalizes policies to advance rural health and
medical innovation. News release. Published August 2, 2020. Accessed
September 30, 2020. https://www.cms.gov/newsroom/press-releases/
trump-administration-finalizes-policies-advance-rural-health-andmedical-innovation.
8. CHART model. CMS website. Updated September 17, 2020. https://
innovation.cms.gov/innovation-models/chart-model.
9. Proposed policy, payment, and quality provisions changes to the
Medicare physician fee schedule for calendar year 2021. CMS website.
News release. Published August 3, 2020. Accessed October 1, 2020.
https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-
and-quality-provisions-changes-medicare-physician-fee-schedule-
calendar-year-4
10. The Cecil G. Sheps Center for Health Services Research. 174 rural
hospital closures: January 2005 to present (132 since 2010). UNC
website. Accessed October 1, 2020. https://www.shepscenter.unc.edu/
programs-projects/rural-health/rural-hospital-closures/
11. Holgash K, Heberlein M. Physician acceptance of new Medicaid patients.
Medicaid and CHIP Payment and Access Commission. Published
January 24, 2019. Accessed October 1, 2020. http://www.macpac.gov/
wp-content/uploads/2019/01/Physician-Acceptance-of-New-Medicaid-Patients.pdf