Community Centers vs Large Institutions: Discussing Differences in Care and Costs

Cancer is almost always an expensive disease, regardless of disease type, treatment type, or location of treatment. That does not mean that there are no differences between those categories, with regard to the location of treatment. Loretta Nastoupil, MD, discussed how these factors affect the costs of treatment.

Nastoupil, who is currently an oncologist at Southwest Oncology in Durango, Colorado, a community center in a rural setting, but previously practiced at MD Anderson Cancer Center, one of the largest cancer centers in the world, was able to speak directly to the differences between those 2 types of care centers. Topics of conversation included differences in insurance interactions, location-specific patient considerations, and travel distance.

Transcript:

CancerNetwork: What are some of the differences between being at a large, state institution vs a rural, community center?

Nastupil: MD Anderson was unique in that it was a cancer center that was affiliated with the University of Texas, and so there were probably large state-based academic programs that were part of the university. We were a subsidiary of that. What I was accustomed to is [having] a large group of ancillary staff. We had a huge number of research staff in the form of research nurses, research coordinators, and staff who handled all the regulatory aspects, such as [institutional review board] and making sure we were up to date on all of our paperwork.

Now I’m in a center where I would love to open clinical trials so that I, again, can serve the community where patients want to stay and live. They don’t want to travel most of the time to receive care, so it would behoove me to open trials in a setting like where [I am] now, given I have an understanding and history of how to conduct trials. There are challenges in terms of who’s going to fund that infrastructure. We don’t have additional staff who can pick up that additional burden in terms of the paperwork aspect of opening trials. That’s a major difference between a large academic practice that’s affiliated with the university vs a community practice that doesn’t have the resources to fund the research infrastructure, which is important if we’re going to continue to provide good quality care to patients and also to train our staff on some of the latest developments, because some of these newer therapies, including bispecifics and CAR Ts, have unique toxicity profiles.

The best way to train everyone who’s going to [engage] with that patient is on a clinical trial, where you have a more controlled environment. You have a protocol that outlines exactly what toxicity to watch for, how to manage it, and you’re usually doing it in a one-case-at-a-time situation where you get to learn. That’s a big disservice to [patients with cancer] in the US: not having access to a number of clinical trials so you can view it through the lens of “it’s experimental” and not “tried and true.” Oftentimes, patients say they don’t want to be our guinea pig. There is a fine balance of trying to provide the infrastructure to do things that are innovative and provide access to the latest and greatest, while doing that in a center where you don’t have the resources to support it.

Are there any differences in dealing with insurance companies between those settings?

Yes. This is where the sole practitioner private practice is disappearing because of the amount of staff that you need just to deal with prior authorizations, making sure patients insurance is up to date, and making sure that we're submitting the right documentation to get reimbursed for things. For a center like mine, we're a part of a larger hospital-based system, so most of the assistance that I receive in terms of making sure we have financial approval to move forward with therapies—and there are differences between IV treatments vs oral therapy—we have 2 different groups that handle those. They are generally centralized in the Denver area, where there's about 4 to 5 different clinics. I’m in Durango, CO…I’m about a 6-hour drive away, and a flight is a little bit easier, but for a lot of our patients, it’s not even feasible. We do rely heavily on the administrative staff in these larger Metroplex areas to provide the support that we need just to function.

How often do you consider whether a specific treatment is too expensive compared with others? How do you approach that with patients?

We have a broad patient population because I’m in a rural community, but I’m also in a desirable retirement community. I do have patients who have fantastic insurance plans, and even they still may be surprised at some of the copayments they may face. We have patients who are grossly underinsured, and in some ways, sometimes that is almost an easier situation, because I work for a hospital that oftentimes will negotiate with patient payment plans. Sometimes those can be quite doable.

Sometimes we get drug provided by manufacturers without any cost to the patient. The problem lies in that there’s so much heterogeneity in terms of what an individual patient may be facing, in terms of their financial burden. Sometimes the middle-of-the-road folks are actually the ones who are impacted the most, where they have insurance, but they have a huge deductible, or it may not be sufficient to cover the ongoing costs. It can definitely eat into their expense. If you live on a fixed budget, for instance, where you don’t have any additional costs, no one anticipates getting cancer. That’s where it can be a huge financial blow to the patient and oftentimes family members. That’s why we do see people go into a tremendous amount of debt, sometimes just when they're trying to deal with a life-threatening problem.

What differences in practice have you experienced since relocating to a community center?

[Lymphoma’s] what I did for 15 years. Now I’m in a setting where it’s a rare disease. I’m in a rural community practice, so now I see more than just lymphoma. I still take care of a number of patients with lymphoma, but I think that’s the other challenge that we face as oncologists in the US. When we start thinking about the practice, if I only did lymphoma in the rural community I face, I wouldn’t be able to function or sustain a practice. It is increasingly more challenging to stay proficient in the management of more than 1 malignancy, just given how rapidly things are evolving in terms of the treatment landscape. I do rely heavily on my local experts, meaning I send patients out to Denver frequently just to make sure that they’re getting access to the most up-to-date options. Then for some of the solid tumor patients I see, I rely heavily on our nurse practitioners, who are very skilled, and our multidisciplinary tumor boards, where we have access to experts across the disease continuum. We have to get more resourceful in terms of how we stay up to date. I’m optimistic that things like AI will help comb through the huge amount of data that’s coming at us regularly. I do know now why people rely so heavily on NCCN, because it does provide you with a guidebook for what is a reasonable choice in a given situation.

Because you’re seeing different tumor types now, have you noticed differences in costs and financial toxicity among patients?

Some of the tumors where we don’t have as much in the way of targeted therapy or immune therapy options, where we’re still relying most heavily on chemotherapy, and colon cancer is a great example of that. In general, some of the older chemotherapy agents are still more cost-effective than some of the more novel newer agents. It still is an intensive treatment regimen for many that can still provide a financial burden to patients, but as we get better at characterizing tumors, identifying targetable lesions, and particularly effective treatments, sometimes that translates into longer therapy with targeted agents that might be more expensive. Ther’'s a great need for innovation and progress to be made, particularly in these solid tumors, where we have far more frequent cases. I also think that sometimes it is partnered with [the fact that] we’re still stuck using chemotherapy agents we’ve been using for the last 40 years.