Suit Up, We’re Going to Capitol Hill

Two million patients will be diagnosed with cancer this year, 2 in 5 Americans. Over half of these patients will require radiation for cure. Annual Medicare costs for all radiation therapy treatments account for less than the annual cost for the top 3 systemic therapy agents, and yet, cuts on radiation therapy payments have been more significant than nearly every other specialty, reaching upward of 22% in the last decade.

These were some of the top statistics at ASTRO’s Advocacy Day this year. I was fortunate to attend for the second year in a row, and it did not fail to broaden my perspectives and open my eyes to the details behind the politics of providing care to cancer patients.

What is Advocacy Day?

Broadly speaking, Advocacy Day is a day of lobbying our state representatives to reform cancer care. It revolves around educating our senators and congressmen, providing critically needed clinical perspective. Day one involves meeting, learning about the major issues at stake, organizing by state, and mobilizing with a strategic plan for lobbying on day two. In essence, we are taught how to lobby and what kind of language is most effective in reaching politicians. One very important tip is to express gratitude and offer an invitation to come see our clinics. We essentially work our bedside manner magic on politicians; we show them the compassion that underscores all our efforts. It is not about political parties; it is about our patients.

Day two is game day. It’s the day you go to Capitol Hill and meet with state representatives and their interns. It’s our time to shine, to make our voices heard, and to help our representatives see why we are so passionate about these issues and why they are so important. By day’s end, your voice may be a little hoarse and you feel pretty wiped out, but you also feel like you really dug into the chain mail that envelopes our government. You feel that you took your best shot to effect real change. You also have grown closer with the radiation oncology community, meeting leaders and allying with your local competitors at home. And you realize that at the end of the day, we all just want to provide the best care for our patients. It is why we are radiation oncologists, and it creates a unified front that can actually chip away at the walls of political stagnation and red tape.

Our Challenges

This year, we advocated for cancer research funding and Medicare payments that are stable, equitable, sustainable, and deliver value to our patients without restricting access. We also revisited a more heated topic: finalizing prior authorization reform.

The first prior authorization reform bill (for any payer market) wasn’t introduced in the Senate until 2019. Anytime there is a manufacturer, physician, or provider vs a health plan or hospital proposal, the bigger guns win. Every time, it’s the health plan or hospital that comes out on top. It takes an army to win one of these issues. Health policy director Charlotte Pineda of Kansas, the “Prior Auth Bulldog,” recalls how her team had to rally around 5,000 organizations to promote the prior authorization reform bill. This was the largest staffer call in the history of the Congressional Budget Office (CBO). Unfortunately, the bill was slapped with a $16 billion dollar score (which is essentially a representation of how a piece of legislation would change federal government spending compared with current law). CBO stood by their statement that due to increased efficiencies of electronic medical record prior authorizations, physicians have more free time to see more patients and bill more to the Medicare Advantage system. Pineda’s team subsequently submitted numerous peer-reviewed research pieces to appeal, but to no avail. As CBO refused to budge, so did Pineda. They kept fighting, with what became the largest coalition under Speaker Pelosi to combat CBO. Eventually, they pushed CBO to publish regulations, which cut the score for the bill in half. Yet these regulations are not yet finalized, which would bring the score of the bill down to zero dollars. It is a bipartisan issue; there are democrats and republicans supporting, and appropriately so. After all, cancer is not partisan.

Thus, our primary driving point this year was getting senators and members of congress to sign and support the prior authorization reform bill. The key barrier is the score.

But insurance companies are feisty, as we all know well from our prior authorization battles. Humana in particular claims they have always supported the bill; they continue to change their tune publicly, which maintains their media image. But the reality is that insurance companies are businesses, and businesses are built for profit, not for patient care.

Moreover, they’ve been weaponizing our medical journals, using isolated pieces of data to deny radiation treatments. What that suggests is that we need more research, more data, to fight back. We need more swords. This is part of why we also advocate for cancer research funding (which I think we can all agree is important not just for prior authorization, but for patient outcomes and treatment strategies).

Of course, we must also consider the cost and burden on physicians. Prior authorization is the No. 1 most reported burden on clinicians. Not only is it incredibly time consuming, but it is also exceedingly frustrating. One interesting point that many physicians at Advocacy Day noted was that our peer-to-peer discussions are increasingly being done with radiation oncologists (not emergency medicine physicians, pediatricians, or other physicians as has been the historical precedent). But when they cite the data, it is clear they are misinterpreting data. And after discussion, it’s not uncommon for them to come around and say, “Oh, yes, I actually agree with you, but I still can’t approve your request.” It doesn’t take long in the field to encounter this frustration; residents become intimately familiar with it early on. The delays in care are also not insignificant and can allow for progression of disease and declining prognosis. To paraphrase ASTRO chair Dr. Geraldine Jacobson, biology doesn’t heed bureaucracy.

My colleagues often ask me why I even bother to lobby politicians. What good will it do? They can’t possibly understand our perspective. But that’s exactly the point. We try to show them why these issues should matter to them. I am not a politician. I am a radiation oncologist who cares about her patients and providing them with equitable, accessible, quality care. They are already fighting cancer and the last thing they should have to worry about at such a critical moment in life (and death) is how to also rally against insurance companies. If not me, then who? As radiation oncologists, we are the ones who see the trickle-down effects of healthcare legislation, dictated by far-removed politicians on Capitol Hill, many of whom don’t even know what radiation therapy is, let alone how critical it is for cancer patients. We must show them. At the end of the day, we have to ffight for our patients.

Thank you to ASTRO for the opportunity to attend Advocacy Day through the EAGL grant and for the very informative sessions beforehand.

Kyra N. McComas, MD

PGY4 resident physician, Department of Radiation Oncology, Vanderbilt University Medical Center.