Denying access to big cancer centers may undermine narrow networks

Patient access to some of the nation's best-known cancer-care centers could become a flashpoint in the simmering controversy surrounding the narrow networks being constructed by some insurers and healthcare providers.

In their efforts to hold down premiums on the new insurance exchanges, many plans have excluded some or all of the nation's most prestigious cancer centers from their provider networks. An Associated Press survey last month of 19 of the 25 institutions affiliated with the National Comprehensive Cancer Network, which writes clinical practice guidelines and whose members conduct cutting-edge research, identified at least 13 centers facing exclusion from a “significant” number of plans.

Only four reported that every insurer included them as a network provider. Even that group reported they were sometimes excluded from low-cost plans.

The exclusion of high-skilled but high-cost cancer centers raises difficult issues for patients in a narrow network if they develop a less common cancer needing specialized care not available in the network. They also may want access to cutting-edge institutions when their cancers progress despite the treatment offered by their local oncologists. Both circumstances probably weren't considered when they purchased more affordable coverage on the exchanges.

“Patients who do not have a cancer diagnosis are not going to ask that question any more than they'll ask, 'What if I get a heart attack?' ” said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society.

But other experts argue that coverage of care at leading cancer centers is not essential for most cancer cases. They say patients can get care that's just as good from community-based oncologists and community hospitals.

Moreover, there's no convincing evidence that the more expensive specialized centers produce better patient outcomes. “We can't determine whether the providers in a narrow network are better than the ones excluded,” said Dr. David Blumenthal, president of the Commonwealth Fund.

The issue driving the exclusions is price. Insurers “are feeling pressure to compete on price in ways they have not felt quite so much before,” Blumenthal noted. When it comes to cancer care, prestigious centers like M.D. Anderson Cancer Center in Houston and Memorial Sloan-Kettering Cancer Center in New York City often charge significantly higher prices than local hospitals or community oncology practices, even when they deliver the same care.

The issue is likely to play out over the coming months as people who purchased the narrow network plans seek cancer care for the first time. Even many community oncologists included in local networks say the restrictions may limit their options.

Dr. Barry Brooks, a Texas oncologist and a spokesman for the US Oncology Network, a group representing more than 1,000 community-based oncology practices in more than 15 states, said access to cancer centers is critical for many patients. “We routinely refer patients who are in desperate circumstances, where therapies have been exhausted, or with rare diseases, where there are no standard therapies,” he said. “I don't think the insurers are looking very much beyond the price tag.”

Still, Brooks said, cancer patients don't have to go to a major academic institution to receive good cancer care in the vast majority of cases. He contends cancer patients can usually get high quality care from local providers, who are equally as good.

Insurance company policies differ on their approaches to approving treatment at leading cancer centers when patients have exhausted local options or prefer treatment at a more prestigious cancer center. Cigna Corp. said that in the five states in which it offers exchange plans, the leading cancer centers are included in its networks.

Humana said its health plans, including those sold through the insurance exchanges, offer access to specialized cancer centers in certain locations, but not all. They note, for example, that the Fred & Pamela Buffett Cancer Center is included in Omaha; the Duke Cancer Institute is available to policyholders in Durham, N.C.; and the UCSF Helen Diller Family Comprehensive Cancer Center is covered in San Francisco.

Its plans will also pay for certain members to receive care at four centers—Memorial Sloan-Kettering; the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla.; the Huntsman Cancer Institute in Salt Lake City; and the UAB Comprehensive Cancer Center in Birmingham, Ala.

On the other hand, the Siteman Cancer Center at Barnes-Jewish Hospital in St. Louis is not covered by any of the exchange plans offered by Anthem Blue Cross and Blue Shield, a major insurer in the area. And in Utah, the Huntsman Cancer Institute is included by five of six Utah insurers but not by Humana, a major carrier. Anthem did not respond to requests for comment.

Last month, the Obama administration issued proposed rules affecting provider networks in exchange plans. Under the rules, federal exchanges will scrutinize plans offered on the federal exchange to see whether they have enough hospitals and specialists in various fields of practice.

While the exact nature of this scrutiny is unclear, insurance industry leaders have expressed alarm about being required to broaden their networks, which they said could drive up premiums.

Aetna CEO Mark Bertolini said at a March 11 investor event that he's wary about CMS plans to closely examine the adequacy of provider networks. If his company still has a lot of uncertainty about the rules regarding exchange plans by the end of April, it will have to propose higher 2015 rates to protect itself, he warned.

The lack of quality and outcomes data justifying higher prices at academic centers, especially for treatment of common cancers, gives insurers a major talking point, according to Dr. Joel Shalowitz, a clinical professor and director of the health industry management program at Northwestern University's Kellogg School of Management. “Show me the data,” he said. “If the academic centers really want to be major players, they're going to have to justify the higher prices or be able to demonstrate superior outcomes.”

While experts interviewed for this article disagreed about whether cancer patients need access to cancer centers as an in-network plan benefit, those working at the major cancer centers believe all patients should have access to their expertise, even in cases that are not rare or complicated.

“The major thing that differentiates our member institutions is that almost all of the faculty (at academic centers) are true experts within specific diseases,” said Dr. Robert Carlson, CEO of the National Comprehensive Cancer Network, which accredits cancer centers. “They are narrow in their focus and are not going to be surprised by an unusual occurrence, especially in the case of rare diseases.”

“Even in common cancer,” he said, “a second opinion by a subspecialist can alter the plan of care.” By excluding coverage in the specialized cancer centers, patients will not have access to that perspective.

The narrow networks may also restrict patient access to participation in clinical trials testing experimental therapies when cancers have advanced. The American Cancer Society's Lichtenfeld said that while some community oncology practices conduct clinical trials independently, much of the research is done at the major cancer centers, which often direct trials and in some cases have full control over all aspects of the study. “If they can't have the patients come in the door, then we slow down drug development and new findings in cancer care,” he said.

Some research supports the argument that cancer patients benefit from being treated at high-volume institutions like the major cancer centers. Findings presented recently at the Society of Gynecologic Oncology's annual meeting in Tampa found that women with ovarian and other gynecologic cancers tended to live about one year longer when they received care at hospitals treating larger number of patients with these conditions, compared with patients treated at lower-volume facilities.

The study authors hypothesized that high-volume centers have better coordination of care, access to clinical trials offering cutting-edge therapy, and access to specialists.

Similarly, survival for patients after lung cancer surgery was greater, especially in the early postoperative period, at higher-volume facilities, according to a 2013 study published in the Journal of Clinical Oncology. And women who had surgery for ovarian cancer at high-volume hospitals were less likely to die if they experienced complications during surgery, according to a 2012 study in the same journal.

Follow Sabriya Rice on Twitter: @MHSRice