City of Hope will further extend its reach by teaming up with more academic medical centers and employers, fueled by a $33 million funding round for its startup AccessHope. Narrow Medicare Advantage networks threaten access, however, a City of Hope executive said.
AccessHope, which Duarte, California-based cancer provider City of Hope launched in 2019 and spun off in 2020, offers employees at more than 400 companies access to specialty care. The program links patients to City of Hope physicians through an affiliate network of academic health systems and cancer centers including Chicago-based Northwestern Medicine, the Dana-Farber Cancer Institute in Boston and Atlanta-based Emory Healthcare.
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AccessHope is one of several City of Hope strategies aimed at increasing access to oncology treatment. The cancer provider also wants barriers to care broken down through state and federal legislation that facilitates early cancer diagnoses among vulnerable populations, changes to Medicare Advantage networks and expanded clinical trials, said Dr. Harlan Levine, president of health innovation and policy at City of Hope and former chief medical officer at UnitedHealth Group’s Optum.
The following conversation with Levine has been edited for length and clarity.
How is the City of Hope using the latest funding round for AccessHope?
The funds will be used to support product and technology development, including the use of [artificial intelligence], to continue expansion of AccessHope’s network of experts. They’ll also be used to engage with more community oncologists while expanding into new markets. AccessHope’s initial clients were large, self-funded employers. Increasingly, AccessHope is also partnering with health plans and health navigation companies that serve mid-sized to jumbo employers. The company has also recently entered its first Medicare Advantage pilot program and is looking to expand its services to the public sector and unions.
We're building into the community, and we think that other academics should build into the community as well. We partner with the community oncologists there, and they can join our practice or we have some specialists that complement their practice. That partnership is how the education takes place. Academic centers should have an obligation to spend a part of their time working with the community oncologist and elevating the care so all boats rise. By having an academic center in every local network, it is a forcing function for communication that might not happen otherwise, and in fact, we're lacking right now.
How is City of Hope trying to meet the growing demand for cancer care?
AccessHope is the reverse of a center of excellence — instead of people coming to us, we disseminate our expertise across the country. We partner with employers and health plans, we identify complex cases through an algorithm analyzing claims data, prior authorization [and] pre-certification data, and then we proactively deliver a second opinion via a subspecialist who reviews the case.
We're actually partnering with a treating doctor, so we're trying to close the gap between what a community oncologist might be able to keep up with and what they should know from a subspecialist. That's taken off. We now have over 400 employers as customers; 7 million members are covered. We grew bigger than what City of Hope could do alone, so we spun it out and have partners that include Johns Hopkins, the Dana-Farber Cancer Institute, Northwestern, Emory and Fred Hutchinson. Each are National Cancer Institute-designated centers that are willing to disseminate their expertise to help improve community medicine.
When we do that, we're able to review the cases to see if the patients are appropriate for advanced care. Are they eligible for a research trial? We know that in the community about 1.3% get on research trials, where in academic centers it is closer to 20-plus percent. We're trying to close that gap between the two and make research more accessible, so not only can patients get better care today, but we learn more for cancer patients in the future.
How is the rise of Medicare Advantage impacting cancer care?
Medicare Advantage programs manage the cost by narrowing the network. Forty percent of Medicare Advantage plans don't have any NCI-designated centers in them. Twenty percent don't have an academic center in a field that is becoming more specialized, more complex. You're actually cutting off Medicare Advantage patients from more advanced therapies.
It makes a difference. In surgical oncology, your 30-day mortality rate for stomach and liver surgery is 50% higher in Medicare Advantage than in traditional Medicare. It's a 100% higher 30-day mortality rate for pancreatic surgery.
Narrow networks are great for primary care and secondary care. But when you really need highly subspecialized care, you need to have access to academic centers and high-volume centers. One of the risks of Medicare Advantage is that we're homogenizing care. It's a good program, except when you have complex care and you need a different solution.
What policies could improve access to cancer care for those with Medicare Advantage?
We need to modernize our definition of network adequacy. The current definition is based on board-certified oncologists within a certain number of miles. But the truth is, you need to have subspecialized expertise. You need to make a requirement that every network has access to an academic center for appropriate cases. Then, you need to define what those appropriate cases are.
In California, we formed a coalition called Cancer Care is Different Coalition. Through that coalition, we were able to enact a law called the California Cancer Care Equity Act that defines what complex cases are so Medicaid patients have a right to access academic centers if their network doesn't have appropriate expertise.
I think that needs to be a universal law. And in fact, we're starting in our Illinois site to work with a local legislature to create a bill of rights, and then we hope to turn that into a similar law. We want to have a national bill of rights and a national [access] requirement for Medicare Advantage. If you create that requirement, not only do you facilitate access into the academic center, but you're accelerating knowledge transfer. Not everything has to go to an academic center, often there's just a knowledge gap. Right now, somehow or another, we pitted community oncology against academic oncology, where it really should be a seamless ecosystem. We’ve let the economics create factions.
On the economics, we need to separate out the cost of oncology, and we ought to be paying for the right oncology to get delivered. As that gets more expensive over time, we have to acknowledge that there will be added cost. But there's so much waste in the system, like step therapy, where you give the lower-cost drug first. Let's do better supportive medicine for the patient, so there's avoidance of unnecessary utilization of emergency rooms and hospitals. Let’s better educate patients so there's less low-value care given at the end of life. About a third of cancer care cost is given in the last year of life.
There are enough intermediaries making profit in the system and there's enough waste in the system that we really can afford to do it right, we just have to set our minds out to do it. And it starts with modernizing the definition of network adequacy, funding cancer separately and funding the right care at the right time with the right supportive care.
How do narrow networks affect access to clinical trials?
As these narrow networks are created, there's an increasing amount of separation from the academic center. Redefining network adequacy will help fuel more clinical research. About half of people don't get the right genomic test with metastatic lung cancer today. Another 15% get the test, but they don't get the right targeted therapy. The majority of cancer patients are not getting optimal care.
The other piece is disparities in health care. African Americans make up about 15% of cancer patients today. I've seen stats ranging from 4% to 7% for the number [African Americans] make up in clinical research trials. African American women have a lower incidence of breast cancer, but they have a 40% higher death rate. If you don't get these underrepresented groups in clinical trials, we will never learn how to take appropriate care. These are the things that we have to study and get people into clinical trials, and I'm afraid that push toward managed care is, in part, synonymous with narrow networks, and is going to cut off access to research.
