The new law, which goes into effect in January, requires Medi-Cal insurance plans to “make a good faith effort” to contract with cancer centers recognized by the National Cancer Institute — which often have access to the latest treatments — or other qualifying cancer centers.
Authored by Democratic Sen. Anthony Portantino of Glendale, it was originally drafted to mandate that Medi-Cal plans add at least one of these cancer centers to their provider networks, but negotiations resulted in a scaled-back version, only requiring health plans to try to add a cancer center.
The law also requires Medi-Cal plans to notify enrollees with complex cancers about their right to request a referral to any of these centers, even if it’s out of their plan’s network. Whether a patient can be treated at one of these centers, however, depends on whether the plan and the out-of-network provider can hash out a payment deal. This referral notification, supporters say, is critical: Patients can’t ask for something they don’t know is an option.
Supporters say that even if limited, this law will be an important step toward helping cancer patients with lower incomes get specialized care.
“I think making incremental change has the ability to save lives and that’s what we’re trying to do here,” Portantino said.
Too often patients from underserved communities arrive at these specialized cancer centers very late after their diagnoses, said Dr. Joseph Alvarnas, hematologist-oncologist and vice president of government affairs at City of Hope, one of eight California cancer centers with a National Cancer Institute designation, and a sponsor of the law.
“The conversation begins with, ‘If I could only have gotten here sooner,’ or ‘My family and I fought tooth-and-nail to get here,’” he said.
Alvarnas said that, historically, City of Hope used to see more Medi-Cal patients, but that changed as the state has largely moved its Medi-Cal program from a fee-for-service model (in which patients could see any provider who accepted Medi-Cal and the state paid providers for each service rendered) to managed care (considered a more cost-effective model, in which the state pays health insurance companies a fixed amount per enrollee).
“In managed care, part of the way that model works is it includes narrower clinician networks and more limited hospital choices,” Alvarnas said. “If you have high blood pressure or you’ve got a condition that can be cared for by many types of doctors, that’s an OK model.
“But when it comes to cancer care, your network of clinicians may not have an expert in leukemia or relapsed myeloma.”
Hospitals sometimes must send some of their sickest patients to cancer centers like City of Hope — as was the case for Patrick Nandy of Whittier. In 2008, during his senior year of college, he was diagnosed with acute lymphoblastic leukemia, a cancer of the blood and bone marrow that can progress very quickly. Nandy said that when oncologists at St. Jude Medical Center could no longer treat him, he was transferred to City of Hope, where he participated in a chemotherapy clinical trial and a cord blood stem cell transplant.
“I think about how lucky I am,” Nandy said. “Doctors said two more weeks and I probably would have been gone.”
These are the types of therapies that should be available to all patients with complex or aggressive cancers, but that’s not always the case, Alvarnas said.
A 2015 analysis by the University of California, Davis (PDF) found worse outcomes for cancer patients with Medi-Cal compared to people with other types of insurance. Among some of the findings: Thirty-nine percent of breast cancer patients on Medi-Cal were diagnosed at an early stage compared to 61% of those who were privately insured.
The study also found Medi-Cal patients diagnosed with early stage lung cancer had a 48% five-year survival rate, lower than the 65% five-year survival rate for those with private insurance. Medi-Cal patients also were less likely to receive the necessary therapies or treatments for several cancer types.
The law will apply to people with rare or complex cancers, including advanced stage brain cancer, lung cancer, colorectal cancer, leukemia and lymphoma, among others, Alvarnas said. The sought- after treatment and research centers include City of Hope, University of California comprehensive cancer centers, the Stanford Cancer Institute, as well as a number of Kaiser Permanente sites and the Cedars-Sinai Cancer Institute.
While the law as passed had no registered opposition, it was watered down during negotiations involving providers, health plans and the California Department of Health Care Services, which oversees the Medi-Cal program.
Health insurance plans initially opposed Portantino’s bill (PDF) because requiring plans to contract with centers, they warned, comes with new administrative hurdles that could disrupt or delay patient care.