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The Centers for Medicare and Medicaid Services has recently proposed reimbursement for Principal Illness Navigation services under Medicare to help patients navigate treatment for serious illnesses such as cancer.
The term “navigation” often evokes images of a map or a GPS, and the experience of trying to find one’s way to an unfamiliar or distant location. Whether through the help of a tool, such as the GPS on your phone or car dashboard, or a person, many people prefer to have some kind of assistance when traveling to a place they haven’t visited before.
In cancer care, a new diagnosis can be frightening for patients, and they may not know where to turn. This is especially true if the patient lacks a strong support system or has few connections to health care providers or a health system. Patient navigators attempt to fill some of these patient needs and help ensure that patients obtain appropriate care and follow their treatment plans. This includes providing personalized help to patients so that they may identify appropriate practitioners and providers for their care needs on time. This is especially important due to the complexity of cancer care and the importance of timely treatment to ensure a patient receives the best outcome. Further, there is compelling evidence supporting navigation services as a solution that helps promote high-quality cancer care delivery. Patient navigators can also help broaden equitable access to cancer care by helping patients locate appropriate providers and supportive services to meet their individual and social needs.
A recent Centers for Medicare and Medicaid Services (CMS) proposal seeks to reimburse "Principal Illness Navigation" services under Medicare to help patients navigate treatment for serious illnesses such as cancer. These benefits would include person-centered assessments, identifying or referring the patient (and caregiver or family if applicable) to appropriate supportive services, practitioner, home, and community-based care coordination, health education, building patient self-advocacy skills, as well as access to comprehensive and equitable care. Additionally, it would include providing the patient with information and resources to consider participation in clinical trials or clinical research as applicable, along with other activities.
CMS’ proposal to reimburse for PIN services under Medicare represents an important step in improving access to comprehensive cancer care. The Association of Cancer Care Centers (ACCC) strongly supports this proposal and has offered its assistance to CMS if implementation moves forward. As part of the implementation process, ACCC proposes that CMS convene a roundtable of expert stakeholders to identify and clarify qualifying navigation certifications and standard navigation metrics.
In addition to obtaining assistance locating and receiving various health care services, patients with cancer often need assistance managing the financial and insurance components of receiving care. Cancer treatments often involve several services provided inside and outside of the hospital setting, such as surgery, radiation, and chemotherapy. Many of these services are costly and the extent to which they are covered by insurance varies. Therefore, some patients may face significant out-of-pocket costs. Additionally, many insurers and coverage plans require "prior authorization," verification that the services are covered by the plan before treatments can begin.
Given the significant financial burdens that may accompany cancer treatments, many cancer centers and programs are establishing financial advocacy or financial navigation programs to assist patients with this aspect of their care. Financial advocates help identify and mitigate financial distress for patients with cancer, their families, and their caregivers. They provide financial counseling, navigation, and/or advocacy services, and are viewed as a key member of the multidisciplinary cancer care team. This, in turn, helps patients access affordable, high-quality care and live an improved quality of life.
Understanding this, ACCC has worked closely with its partners and stakeholders to develop guidelines for financial advocacy services. The guidelines include the following considerations:
Patient and financial navigation are important components of the multidisciplinary cancer care continuum. CMS’ proposed PIN regulations and Medicare reimbursement, if finalized, will help promote the provision of these services to patients with cancer who are covered by this program. With respect to the financial aspects of cancer care, ACCC’s Financial Advocacy Network provides a range of training opportunities to help enable the provision of high-quality financial advocacy services. Together, these services work to promote equitable access to high-quality cancer care. For more information on the ACCC Financial Advocacy Network, please visit the website.
Nicole Tapay, JD, is Director, Cancer Care Delivery and Health Policy, Association of Cancer Care Centers, Rockville, Maryland.