ASCO Reading Room | Ramy Sedhom, MD, on Payer Coverage of Integrative Treatments for Symptom Control


Despite advances in cancer treatment and improved survival, more than 50% of patients continue to suffer from poor pain control. Integrative interventions such as acupuncture have been shown to provide safer and more effective analgesia than opioids, but lack of payer coverage remains a major barrier.

Writing in a recent editorial in JCO Oncology Practice, Ramy Sedhom, MD, of Penn Medicine-Princeton Medical Center, and colleagues point out that there is also insufficient coverage for integrative therapies such as mindfulness-based stress reduction, massage, transcutaneous electrical nerve stimulation, and therapy. therapeutic exercise. These non-pharmacological techniques have demonstrated clinical benefits in managing other physical, emotional and existential symptoms associated with cancer, the authors said.

“It is time to implement integrative oncology in practice,” the team wrote. “Patients ultimately suffer when access to safe, minimally invasive and effective non-pharmacological interventions is limited… It is our responsibility as healthcare professionals to advocate for better coverage of non-pharmacological interventions to alleviate the suffering of our patients and minimize their financial burden.”

Currently, payer coverage for integrative cancer interventions does not reflect ASCO and National Comprehensive Cancer Network (NCCN) guidelines. For example, the 2021 NCCN guideline update recommends optimization of integrative therapies and highlights the use of acupuncture for the treatment of pain, fatigue, nausea, vomiting, and flushing. heat in palliative care and survivorship settings.

Additionally, more than 80% of NCI-designated cancer centers recommend acupuncture for symptom management. “This contrasts with drug coverage, where nearly all payers, including Medicare, use NCCN guidelines and compendiums as formal guidance for coverage determinations, resulting in much broader coverage,” they said. said Sedhom and his co-authors.

They noted that the burden of proof to demonstrate a return on investment with integrative techniques aimed at pain prevention and control is higher than the norm for treatment services. As a result, there is an overinvestment in low-value treatments, such as pharmacological management of chemotherapy-induced peripheral neuropathy, and an underinvestment in preventive or associated therapies such as acupuncture.

“Integrative oncology researchers have before them a wonderful opportunity to conduct pragmatic symptom control trials that compare conventional and integrative medicine approaches, focusing on efficacy (including long-term effectiveness of symptom control symptoms and the broader impact on health domains), safety and toxicity of interventions, patient burdens, and costs to patients and payers,” the authors wrote.

Ironically, however, they said, breaking down barriers to integrative oncology coverage may require a new paradigm. “Payers are increasingly recognized as influential stakeholders who are well placed to drive change in practice. Increased advocacy is needed to match resources, policies and coverage of integrated symptom control services to the needs of the people we serve. »

In the following interview, Sedhom, who is an assistant professor of clinical medicine at the University of Pennsylvania’s Perelman School of Medicine, discussed the issues in more detail and shared a vision for the future of healthcare.

Was there a specific incident or recent study that prompted you to write this op-ed?

Sedhom: A patient of mine found acupuncture to be more helpful for her cancer pain than opioids or other pharmacological therapies, but she stopped after a few sessions. I learned later that it was due to the cost, which was not covered by insurance. She was paying $100 out of pocket per session. This prompted some to dig into this problem, which we now know is common.

There was a time when Western medicine viewed integrative interventions with great skepticism. Now, such procedures are recommended in ASCO and NCCN guidelines, and doctors practice acupuncture. How did we come here?

Sedhom: In general, Western medicine has struggled to integrate these aspects of holistic personal care into disease management. Just look at the money spent on chemotherapy trials in cancer versus work focused on alleviating pain and suffering.

We’ve known for years that lifestyle, diet, emotional distress, and social environment impact patient outcomes across the healthcare spectrum. It is only recently that we have begun to diligently measure their impact, although carrying out such studies is difficult due to limited resources, both financial and structural.

We know from national surveys that patients identify integrative and complementary medicine as important, so this may have been a nudge to pay more attention to it.

In your editorial, you said that integrative care needs to be better coordinated with the other specialties of the cancer care team and that the coordination between pharmacological and non-pharmacological therapies needs to be improved. Any suggestions on how?

Sedhom: The first step is investment by institutions and payers. It shouldn’t be easier to order a $100,000 limit beneficial drug than to refer a patient to a specialist focused on improving the patient’s social, psychological, physical, emotional, and existential crisis. We’ve seen greater uptake of palliative care in value-based payment models when it impacts a practice’s bottom line, for example.

In your expert opinion, what will it take to change insurance policies that focus primarily on drug therapy coverage? Do physicians have a role to play beyond creating expert guidelines that recommend integrative care?

Sedhom: The structure and delivery of incentives ultimately shape behavior. Clinicians are too busy, and unless integrative care teams are immediately available, both physically and from a reimbursement perspective, we cannot expect benchmark models to develop.

Payment reform is fundamental to this shift to value-based care that we’ve heard about but don’t seem to see. Incentives for change must be meaningful. I think these issues go beyond any simple medicare or physician advocacy solutions.

ASCO guidelines recommend music therapy, meditation, stress management and yoga for anxiety in breast cancer patients. However, concretely, how do we intervene? The incentives to devote any attention to this are minimal at present.

Do you have anything else to say to the clinician readers?

Sedhom: If you have listened to music after a hard day at the clinic, or found exercises or massage therapy, you have identified the principles of integration as important in your own life. I hope that those in a position of change can one day restructure our focus on helping patients achieve optimal health rather than focusing on treatment.

Read the study here and expert commentary on the clinical implications here.

Sedhom has declared no potential conflict of interest; one co-author said he was employed by Merck, and another reported relationships with Dendreon, Omnitura, and Exelixis.

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