Alaska Cancer Care Alliance Org Content Uploads 2012 July

Takeaways

Cancer rates and cancer deaths have been falling in the United States. And yet, cancer care is riddled with issues. The toll of care for patients is just likewise high. Despite high costs, the quality of care varies widely with too much intendance that is plagued by racial and indigenous inequities and not evidence-based. In this report, nosotros propose a new, innovative approach for Medicare to finance all cancer care through cancer care organizations (CCOs), which would be accountable for all aspects of cancer care, from the quality of care to patients' costs. Medicare tin can bulldoze changes across the health care arrangement by encouraging private sector participation in CCOs.

"The medical institution tells me I have 'failed' a number of therapies. That's not correct: The establishment and its therapies take failed me. The system we alive in every bit metastatic breast cancer patients is simply not designed to deal with the cycle we are living and dying in," wrote LA Times reporter Laurie Becklund shortly before she died of chest cancer.^one She spoke the truth about the frustration and disappointment of many cancer patients. All as well ofttimes, cancer care fails patients subsequently putting them through excruciating therapies. It is no one's fault that cancer is very hard to forestall and cure, but so much of current handling and financing is not leading to improve outcomes and experiences for patients.

With cancer rates and deaths falling in part due to improved screening and smoking prevention, cancer care itself is the next big wave of improvement in the war on this disease. Electric current treatments and new ones on the horizon show bang-up promise for curing cancer, but only if they are deployed effectively. And, correct now, people of color are not experiencing the full extent of these gains, and costs are rising for patients and the whole health care system.

It is time to replace the fragmented payment system for cancer care with 1 that drives quality, equity, value, and innovation. In this study, we identify the key problems with cancer intendance in the Us and explicate why current efforts are failing to fix care. We then suggest a new, innovative approach that Medicare finance all cancer care through cancer care organizations (CCOs), which would be answerable for all aspects of cancer care from providers' to patients' costs, and encourage individual wellness plans and employers to employ them. This proposal will help achieve the goal of President Biden'due south Administration to have all beneficiaries in traditional Medicare "in a care relationship with accountability for quality and total toll of care past 2030.²

Three Major Bug with Cancer Care

Cancer care in the Usa has three major bug:

1. The cost of cancer care for patients and the whole wellness care system is simply too high.
2. Despite spending and so much, the quality of cancer intendance varies widely.
3. This quality variation leads to severe racial and ethnic inequities.

High Costs Overall and for Patients

The United States spends a lot of money on cancer care, and costs are ascent. In 2015, the United States spent well-nigh $183 billion on cancer-related wellness care.ⁱⁱⁱ These costs are expected to increase to $246 billion in 2030 based simply on population growth, not considering potential loftier-priced advances in cancer treatment. Information technology is no surprise that almanac per capita wellness care expenditures for cancer patients are nearly four times higher than for patients without cancer.⁴ Every bit cancer rates fall, overall spending for cancer care is growing more slowly than spending for all other illness categories. Merely the cost to care for each case of cancer is growing more speedily than the average treatment cost for other diseases.⁵

The high cost of care is at least partially driven by prices for some cancer drugs that are too loftier given their value. For case, a value-based assessment of three chemotherapy drugs for recurrent ovarian cancer found prices were $6,900-8,850/calendar month too loftier given their value, though some have questioned whether this assay adequately included patient perspectives on the drug'south value.^half-dozen

Cancer patients shoulder many of these costs themselves, out of their ain pockets, regardless of insurance coverage status. Cancer patients paid $v.6 billion in out-of-pocket costs in 2018 solitary, with average per patient costs of $3,600.⁷ Yet, per patient costs range widely, from $2,160-$31,200 per year.^viii In many cases, the costs are prohibitive and a patient'southward health suffers—a phenomenon known as financial toxicity, which is associated with worse outcomes and poorer quality of life.^ix Health insurance is not necessarily protective against financial toxicity. A study of colon cancer patients, about all of whom were insured, found that near 25% of patients had treatment-related debt with an average debt of more than $26,000.¹⁰

While Medicare beneficiaries by and large take amend protection confronting costs, they practice written report fiscal toxicity, depending on the type of supplemental insurance in which they are enrolled. Medicare beneficiaries without supplemental insurance are fully exposed to a 20% coinsurance for most cancer care covered under Part B, including most chemotherapy, and a 5% coinsurance for Role D drugs when costs exceed the catastrophic coverage limit. Beneficiaries dually enrolled in Medicare and Medicaid experience the lowest boilerplate annual out-of-pocket costs ($2,116), while beneficiaries without any supplemental coverage experience the highest costs ($8,115).¹¹

Costs are non borne every bit by all cancer patients, and there are substantial racial, income, and educational disparities in the distribution of out-of-pocket costs. People of color and patients with lower incomes and less formal education were more than likely to experience financial hardship.¹² African American cancer survivors were more likely than white survivors to experience fiscal toxicity (31% versus 24%).¹³ Among chest cancer patients, Black women are more likely than white women (58% vs 39%) to study an agin financial impact of cancer.^fourteen

Wide variation in cancer care

Cancer mortality has fallen 31% since 1991, more often than not because Americans are smoking less and there are new and more than effective screenings and treatments for certain cancers.¹⁵ For instance, the death rate for lung cancer saw substantial improvement between 2014 and 2018, likely due to handling breakthroughs for non-small prison cell lung cancer.^sixteen Despite this, it is important to note that the decease rate from some cancers like pancreatic, liver, mouth, and throat, is rising.

While a general decline in the decease rate is good, cancer care still falls well brusque of where it should exist. Every bit UCLA oncologist and researcher Patricia A. Ganz has said, cancer intendance in the Usa "falls short in terms of consistency in the delivery of care that is patient-centered, evidence-based, and coordinated."¹⁷ Nosotros see this wide variation play out in different ways:

• Non all cancer intendance is accountable for outcomes that matter to patients. The manner medical professionals and Medicare appraise quality-of-care focuses on modest details like the delivery of a specific service instead of the results of the care. A comprehensive set of oncology outcome-based quality measures has not been published, and event-based measures do not be for many cancer specialties.¹⁸ The National Quality Forum's Core Quality Measures Collaborative core measure set for medical oncology is focused by and large on process measures, and the Collaborative notes that patient reported outcomes and patient feel measures "remain a challenge and a priority area for oncology."^xix
• Non all cancer intendance is bear witness-based . Prove-based Clinical Practice Guidelines exist for 97% of cancers in the United States.²⁰ Unfortunately, adherence to the guidelines varies widely in oncology, ranging from equally high as 96% for head and neck cancer²¹ to as depression as 35% for pancreatic cancer²² and 37% for ovarian cancer.²³ Adherence to the more than than seventy Choosing Wisely recommendations for cancer care, which focus on tests and procedures that lack show and fail to add together value, ranges from 53% to 78%, and the initiative has had little impact on reducing wasteful, low-value care delivered at hospitals and clinics throughout the country.²⁴

• Non all cancer care is coordinated. ²⁵ Cancer care remains hard for patients to navigate. Most cancer patients receive more than one blazon of treatment and must coordinate care received from a surgeon, oncologist, radiologist, and more. These providers may not be in the same clinic, practice, or even the same wellness system. The consequences of this lack of coordination can be catastrophic. Equally one study succinctly noted, "Poor care coordination during cancer treatment is associated with medical errors and sentinel events, poor symptom command, less-comprehensive supportive care, and increased utilization and costs."²⁶

Unequal Outcomes

This wide variability contributes to severe racial and ethnic inequities in cancer intendance and health outcomes.²⁷ Racial and ethnic minorities, along with individuals of lower socioeconomic status and those who are uninsured, have a much higher incidence of sure cancers and are more likely to exist diagnosed at later stages in their disease, which contributes to disparities in cancer survivorship.²⁸ Racial and ethnic minorities are also less likely to receive standard treatment for cancer just as they are for health care in general.²⁹ Hither are some key examples:

• Blackness Americans are ane-tertiary more likely to die from cancer after accounting for other factors similar age and phase of diagnosis.^thirty
• American Indian and Alaska Natives are 51% more likely to die from cancer. ³¹
• Black men die from prostate cancer at a rate more than double that for all other men. ³²
• Black women accept a 40% higher chest cancer death charge per unit than white women, despite having lower rates of diagnosis.³³
• Hispanic Americans are less probable to die from cancer generally simply have higher expiry rates for specific cancers like stomach, cervical, and liver.³⁴

Research indicates the causes of these disparities are a complex combination of systemic and structural racism. Contributing factors include "barriers to high-quality cancer prevention, early on detection, and handling due to interrelated inequities in piece of work, wealth, teaching, housing, and overall standard of living."³⁵ As an commodity for the American Society for Clinical Oncology succinctly puts information technology: "The differences in cancer survival are related to structural barriers to accessing care and overt documented differences in the commitment of evidence-based care."³⁶

Socioeconomic disparities in cancer are persistent and widening, particularly for preventable cancers.³⁷ For example, death rates in the poorest counties in the United States are 2 times higher for cervical cancer and xl% higher for lung cancer (in men) and liver cancer than expiry rates in the wealthiest counties.³⁸

Black men die from prostate cancer at a rate more than than double that for all other men.

The COVID-19 pandemic will likely exacerbate these disparities as many Americans missed or delayed important cancer screenings due to public wellness measures to mitigate virus spread. For example, in April 2020, chest and cervical cancer screenings declined by 87% and 84% compared to five-year averages for that calendar month, with even greater declines for breast cancer screening amid American Indian and Alaska Native women (98%) and cervical cancer screening among Asian Pacific Islander women (92%).³⁹ The consequences of these missed or delayed screenings may include cancer diagnosis at much later affliction stages, a cardinal factor in worse bloodshed rates.

Why Current Efforts are Falling Brusque

Current efforts have not yet taken a comprehensive approach to all aspects of cancer intendance—from coordination to quality—and overall costs for cancer patients.

For example, the Centers for Medicare & Medicaid Services (CMS) has not attempted a comprehensive cancer payment model that prioritizes and incentivizes coordination beyond multiple providers. Contempo efforts by CMS have focused on patients receiving just one attribute of cancer treatment—just chemotherapy or only radiotherapy—when most cancer patients receive multi-pronged treatment. Specifically, the Oncology Care Model has focused on Medicare beneficiaries receiving chemotherapy.^twoscore

Despite not achieving overall savings through the first five operation periods, the model has been successful in important ways. Medicare Part A payments to providers nether the model declined more for those in a comparing group, and Role B payments to providers nether that model grew more slowly than payments in a comparison group, both without hurting patient satisfaction.⁴¹ The payment differential has increased over time, suggesting that the model could somewhen produce a internet savings. In addition, the relative payment reduction has been greater in higher-chance episodes of care, where the Oncology Intendance Model has reduced Medicare Parts A and B payments below projections.⁴² Finally, this model has pioneered of import new elements similar a written handling programme, which patients can study on their own time and not simply when they are overwhelmed by data at a doctor's part.

CMS has also finalized an alternative payment model using a bundled, episode-based payment for radiotherapy treatment.⁴³ Radiations oncology accounts for just iii% of costs for actively treated cancer patients in Medicare, but fee-for-service payments to providers vary widely depending on the location where care is provided.⁴⁴ The Radiation Oncology Model aims to accost this while improving quality and adherence to evidence-based care. A major claiming is that CMS' ii cancer care Models don't work in tandem, with the Oncology Care Model having to reconcile costs that are incurred nether the Radiation Oncology Model. The lack of integration means there is no incentive for care coordination.

Another missing element in CMS' payment models for cancer care is the price of drugs, which constitute a substantial share of the total toll of cancer care and are ascension.⁴⁵ Estimates of the portion of cancer costs dedicated to chemotherapy and other drugs range from 18-fifty%.⁴⁶ Without addressing pharmaceutical prices, and the substantial share of those prices borne by patients, electric current models fail to address barriers that may jeopardize patient admission to potentially life-saving medications.

The Solution

We need a new approach to cancer care—1 which reduces costs and improves quality for all patients. To accomplish this, Congress should work with the administration to finance cancer intendance through cancer intendance organizations (CCOs), which would receive a value-based payment to improve the quality of intendance, lower overall costs and patient costs, and ensure disinterestedness among patients of unlike demographic backgrounds. Similar an accountable intendance organization, the payment would cover health care costs while receiving treatment and follow-upwards care. To ensure continued customs access to cancer care, CCOs would either be accountable for all health care costs or cancer costs but, depending on the experience and infrastructure of the CCO. Building on the CMS models, a CCO would give providers total responsibility for cancer care and would leverage Medicare's market-leading power to drive modify for all patients with cancer.

Creating CCOs volition require the following five steps:

one. Develop outcome-based cancer care quality measures that affair to patients. Medicare should measure and pay for the kinds of things that matter to patients. For example, some patients may want to know how well they tin can wait to function during and after treatment, some may prioritize extending life equally long as possible, while others may emphasize their quality of life and prioritize palliative or hospice care. To address this, the National Coalition for Cancer Survivorship facilitated a patient-driven measurement development effort focused on redefining functional status during handling and into survivorship.⁴⁷ Prioritized domains in this measure include global quality of life (including concrete and mental health), concrete role, pain, fatigue, cognitive function, and psychosocial affliction impact (such equally depression, independence, sense of control, and others).⁴⁸ Quality measures should also reflect how effectively clinicians have engaged patients in shared decision-making about treatment options, including palliative, hospice, and end-of-life intendance.⁴⁹ Ultimately, provider performance on these quality measures will, in part, make up one's mind payment rates nether value-based arrangements described below.

To continue progress toward developing patient-centered, outcome-based cancer care quality measures, CMS should proceed with the quality measure lifecycle, using existing cancer care models and CCOs to collect data, refine measure out specifications, ascertain technical details, and more.⁵⁰

Medicare should measure and pay for the kinds of things that matter to patients.

 ii. Use value-based payments to drive disinterestedness, quality, savings, and innovation. CCOs will have responsibleness for the cost and quality of cancer care for assigned beneficiaries through value-based payment arrangements that drive equity and encourage innovative treatment options.

In society to maintain customs access to cancer care, payments to CCOs will differ based on providers' experience and infrastructure. Payments to larger CCOs with the infrastructure and experience to assume full responsibility for patient intendance volition encompass all Medicare items and services during a six-month episode of care. CCOs that run across quality and equity requirements will share in whatsoever savings they achieve. CCOs serving smaller communities volition also exist paid for a six-month episode of care, simply payments to these providers will encompass cancer-related items and services merely, with bonus payments for meeting quality and disinterestedness requirements.

The payment to CCOs for each patient will include pharmaceutical costs, which should incentivize CCOs to use lower-cost generics and biosimilars when bachelor. Emerging data signal biosimilar utilization is beginning to drive savings among the oncology care model participants.⁵¹ In addition, CCOs will be able to negotiate value-based payments for cancer drugs that are based on measurable benefits to patients.⁵² In the U.South., these arrangements are rapidly becoming more mutual between health plans and manufacturers, simply medical groups are often non involved. In France, hospitals and hospital purchasing groups negotiate direct with pharmaceutical manufacturers to fix the toll for injected and infused drugs used in the hospital ambulatory or inpatient setting.⁵³ A gainsharing framework with the French single-payer wellness care arrangement encourages hospitals to negotiate the best possible cost.

To begin progress toward value-based payment for prescription drugs, the Department of Wellness and Human being Services (HHS) should collect information on off-characterization utilize of cancer treatments by CCOs to gather real world prove on their performance and value. This could involve Congress working with states to require prescribers to annotation the specific indication or illness on their prescriptions or establishing confidential registries of off-label prescribing.⁵⁴ In addition, Medicare should attribute Part B and Office D drug costs to patients and providers participating in the CCO. Finally, CCOs would exist expected to accelerate the evolution and utilization of decision-support tools that integrate clinical and economical data into a single system for clinicians to use when discussing treatment options with patients.⁵⁵

To ensure these changes improve intendance and outcomes for all patients, part of a CCO'south payment would include a reward or penalty based on health disparities.  For case, if a CCO improved its quality scores for people of color likewise for all its other patients, then information technology would receive a full bonus. As a first step toward tying payments to disinterestedness, CMS should crave providers to submit relevant data, which will assistance advance piece of work already underway to improve data collection and design interventions to accelerate health equity. A near-firsthand use of such data could exist to compare the racial and ethnic composition of a CCO's patients to like data of its community, to make up one's mind whether a CCO serves a patient population that reflects its community.

Finally, a fixed percentage of each CCO's value-based payment volition be earmarked for innovative preventive, diagnostic, and handling methods, and for investments in infrastructure, such every bit data systems infrastructure that supports this new, comprehensive, coordinated model of care. For example, oncologists may wish to employ new blood tests for detecting multiple cancers before they are officially canonical for Medicare reimbursement.⁵⁶ Medicare would base of operations the corporeality for the innovation fund in role on economical analysis of the value of innovative methods and products as they become available for apply. The decision about how to utilize the innovation fund would be up to the CCO. That way, the innovation fund would give clinicians flexibility to avoid conflicts betwixt older treatments and experimental treatments as well every bit the opportunity to enroll patients in clinical trials concurrently.⁵⁷

3. Remove statutory and regulatory barriers to value-based arrangements. Electric current policies aimed at preventing waste and fraud nether the old payment organisation chosen fee-for-service are inhibiting the adoption of new, value-based payments. For example, the Anti-Kickback Statue and Stark Constabulary preclude providers and suppliers from conspiring to share money gained from bilking Medicare but have likewise historically prevented suppliers from sharing technology that can enable providers to utilize their products more successfully. In improver, the Medicaid best price dominion has had the unintended effect of limiting the scope of private sector arrangements that lower prices below what Medicaid currently pays.

A next stride to clearing a regulatory path for value-based arrangements would exist to fully employ recent regulatory exceptions to the Stark Law for value-based arrangements to the Anti-Kickback Statute, and then that budgetary remuneration is protected regardless of the amount of financial risk undertaken by participants. In addition, HHS should explore ways to allow pharmaceutical manufacturers to utilise recently created condom harbors from the Anti-Kickback Statute to help solidify legal certainty for entities seeking to participate in value-based arrangements, including CCOs. Such an endeavour should likewise back up a new dominion that ensures the value-based arrangements for drugs can move forrad as immune nether the new Medicaid best price rule while ensuring state Medicaid programs have access to the aforementioned low prices through value-based arrangements and to not-value-based best prices for states that are unable to participate in value-based arrangements.⁵⁸

4. Protect patients from high costs. Medicare would cap out-of-pocket costs for all patients based on income by filling gaps in existing programs like Medicare Function D for prescription drugs and the Medicare Savings programs for depression-income beneficiaries.⁵⁹ In addition, CCOs would have the flexibility to set patient cost-sharing in a way that optimizes access to care and recovery from cancer. Finally, CCOs would be permitted to use value-based insurance design to encourage utilize of high-value health care items and services and help reduce costs for patients with loftier wellness care needs. This would likely involve awarding of waivers for patient engagement incentives, such every bit the cost sharing support for Part B services available in some models tested by the Center for Medicare and Medicaid Innovation. Without such a waiver, the Anti-Kickback Statute would limit providers' ability to waive copayments unless certain criteria are met.⁶⁰

v. Sequentially stage-in the CCO model. To support participants' success, nosotros urge CMS to employ an explicit program with transparent criteria for moving through a serial of steps like those outlined by the Health Care Transformation Job Force. Those steps include involving stakeholders in designing the model, prioritizing simplicity and transparency in model design, moving gradually to full financial responsibility for organizations managing the run a risk of paying for patients' intendance, and carefully considering overlap with existing CMS payment models and ways to synchronize them.⁶¹

Conclusion

Cancer rates and cancer deaths have been falling in the United States, but cancer remains the second leading crusade of decease and the price of treating cancer continues to rise.⁶² Cancer care is often high-priced and is not bear witness based, meaning the nation does not become a good value for the cost. And variation in cancer intendance as well produces unequal results for people of color and of lower socioeconomic condition.

Recent efforts to better cancer care in Medicare have helped in some cases but lack a comprehensive approach. Medicare should build on these efforts and create cancer intendance organizations (CCOs), which would be accountable for all aspects of cancer care, from the quality of intendance to patients' costs. CCOs would receive value-based payments that advantage providers for eliminating wasteful care, improving outcomes for patients deservedly, and protecting patients from high costs. This CCO payment model would leverage Medicare's leadership ability to drive alter for all patients with cancer.

Appendix - Barriers to a Comprehensive Approach to Cancer Care

In improver to piecemeal innovation models from CMS, several other issues impede a comprehensive approach to cancer care as noted below.

Existing event measures practise not provide comprehensive accountability for the things that matter to patients. The Agency for Healthcare Research and Quality regards outcome-based measures as the gold standard in quality measurement. Even so process-based measures boss many oncology quality assessment frameworks, including CMS' Oncology Care Model and Radiation Oncology Model. Outcome measures that do exist exercise non focus on what matters virtually to patients.⁶³ Measuring and reducing unnecessary utilization, such as hospitalizations and emergency department visits, is certainly of import, but patients too care about how well they live with cancer and across.

Decision-support tools that integrate clinical guidelines and value-based recommendations when multiple treatment choices are emerging, thanks in function to demand created by the Oncology Care Model, but are non yet widely utilized. Value-based intendance benchmarks for cancer therapeutics have helped reduce costs but are not used beyond the entire health care system. While clinical guidelines help to define loftier-value, evidence-based intendance, they often include multiple treatment choices with no preferential order.⁶⁴ The claiming remains to move from practice guidelines to a clear value metric for a specific cancer therapeutic. In the U.S., the American Society of Clinical Oncology (ASCO) Value Framework and National Comprehensive Cancer Network (NCCN) Evidence Blocks attempt such a definition, aiming to help clinicians and patients cull betwixt existing, comparable treatments, merely both have shortcomings.⁶⁵ The Institute for Clinical and Economic Review (ICER) framework considers clinical and economic data to measure how well a particular intervention improves and lengthens patients' lives. ICER takes into account both long-term value and short-term affordability to set a value-based cost benchmark.⁶⁶ Using this framework, ICER has found that chimeric antigen receptor t-jail cell (CAR-T) therapies are cost-effective for certain patients despite wholesale acquisition costs between $375,000-475,000.⁶⁷ On the other manus, ICER found that discounts of 57-78% off the costs of several ovarian cancer maintenance drugs were required in lodge to meet cost-effective benchmarks, despite those drugs having a much lower cost than the CAR-T therapy.⁶⁸ The ideal conclusion-support tool would seamlessly integrate clinical and value decisions into a clinician's workflow and enable them to appoint patients in controlling about handling choices.⁶⁹

Routine bear witness evolution and data collection of off-label uses of oncology drugs are largely nonexistent. Researchers approximate that more half of oncology drug use is off-label.⁷⁰ Off-label use of a drug ways, for instance, it is prescribed past a clinician for an indication, at a dose, for a duration, or for a patient different from the precise requirements for which the Food and Drug Administration (FDA) approved the drug. Because the FDA regulates the drug and the manufacturer, but states regulate clinicians and pharmacies, physicians may generally (except in certain restricted circumstances) prescribe an FDA-approved drug for uses beyond the label.⁷¹ Medicare and many commercial insurance payers embrace drugs used off-characterization and so long as the off-label uses are included in an approved drug compendium.⁷² However, states exercise non require physicians to include on a prescription the reason for prescribing a drug, which makes information technology challenging for existing databases to determine when a drug is beingness used off-label. One helpful development is a recent draft FDA guidance on ways to standardize the use of data from the off-characterization apply of drugs and other uses, which could lead to more show development and data collection.⁷³

Efforts at paying for value are limited by statutory and regulatory barriers. Several pregnant statutes and regulations make implementation of value-based wellness intendance payment models and contracts challenging for a wide diverseness of health care organizations.⁷⁴ In tardily 2020, the Trump assistants finalized regulatory changes to the Stark Law and Medicaid best-price dominion to provide greater flexibility and help advance greater adoption of value-based payment arrangements.⁷⁵ Even so, meaning hurdles to value-based care arrangements between payers and providers remain. The Anti-Kickback Statute inhibits the creation of value-based payment and contracts in all segments of the health intendance industry. In addition, FDA rules and policies on communication by pharmaceutical and medical device manufacturers about medical products limit, in certain circumstances, the cess of clinical benefits of intendance, the sharing of toll data, and the degree of cost savings.

Patients do not have comprehensive protection from financial toxicity. Wellness intendance costs present a serious feet for most Americans, fifty-fifty those who take health insurance coverage.⁷⁶ Current efforts, including proposed limits on drug prices and the recently enacted ban on surprise bills, are good and of import, but do not comprehensively address a patient'due south total price problem.⁷⁷ They do nothing to guarantee that patients' costs volition not go along to explode. And they do not control all the other underlying causes of high costs including wasteful care, high provider prices, and administrative overhead.⁷⁸

Information on racial and ethnic disparities is incomplete and existing data highlight a wellness intendance system that is failing people of colour. Through Executive Orders, President Biden has directed federal agencies to begin work on foundational data challenges and Congress is as well working on standards and definitions.⁷⁹ This work is in early on stages and must be connected to accurately mensurate disparities and design interventions to eliminate them.

Endnotes

1. Becklund, Laurie. "As I Lay Dying." LA Times, 20 Feb. 205, www.latimes.com/opinion/op-ed/la-oe-becklund-breast-cancer-komen-20150222-story.html. Accessed 27 Aug. 2021; Cavallo, Jo. "Using Respectful Language to Reduce Unconscious Bias in Oncology Care: A Conversation with Tatiana M. Prowell, Md." The ASCO Post, 10 Apr. 2020, https://ascopost.com/issues/apr-10-2020/using-respectful-language-to-reduce-unconscious-bias-in-oncology-care/. Accessed iv Jan. 2022.

2. U.s.a., Department of Health and Human Services, Centers for Medicare & Medicaid Services. "Strategic Direction." v Nov. 2021, https://innovation.cms.gov/strategic-direction. Accessed iv January. 2022.

3. Mariotto, Angela B., et al. "Medicare Care Costs Associated with Cancer Survivorship in the United States." Cancer Epidemiology, Biomarkers and Prevention, July 2020. cebp.aacrjournals.org/content/29/7/1304. Accessed 4 Jan. 2022.

4. Park, Poohyun and Kevin A. Look. "Health Care Expenditure Burden of Cancer Care in the Usa." Inquiry: A Journal of Medical Intendance System, Provision, and Financing, 4 Mar. 2019. www.ncbi.nlm.nih.gov/pmc/articles/PMC6778988/. Accessed iv Jan. 2022.

5. Gonzalez, Selena and Cynthia Cox. "What are recent trends in cancer spending and outcomes?" Peterson-Kaiser Family Foundation Health System Tracker, 10 Feb. 2016. world wide web.healthsystemtracker.org/chart-collection/recent-trends-cancer-spending-outcomes/#item-average-growth-per-capita-spending-cancer-slightly-lower-boilerplate-disease-categories. Accessed 4 Jan. 2022.

6. "A Await at PARP Inhibitors for Ovarian Cancer." Institute for Clinical and Economic Review. Sep. 2017, p. 3. icerorg.wpengine.com/wp-content/uploads/2020/10/Ovarian_RAAG_092817.pdf. Accessed 4 Jan. 2022.

7. "The Costs of Cancer: 2020 Edition." American Cancer Society Cancer Action Network. Oct. 2020, p. 3. www.fightcancer.org/sites/default/files/National%20Documents/Costs-of-Cancer-2020-10222020.pdf. Accessed 27 Aug. 2021; Iragorri, Nicolas et al. "The Out-of-Pocket Toll Burden of Cancer Intendance-A Systematic Literature Review."Current Oncology, 15 Mar. 2021. https://pubmed.ncbi.nlm.nih.gov/33804288/. Accessed 4 January. 2022.

8. "The Costs of Cancer: 2020 Edition." American Cancer Society Cancer Action Network. Oct. 2020, p. three. www.fightcancer.org/sites/default/files/National%20Documents/Costs-of-Cancer-2020-10222020.pdf. Accessed 27 Aug. 2021; Iragorri, Nicolas et al. "The Out-of-Pocket Price Burden of Cancer Intendance-A Systematic Literature Review."Current Oncology, 15 Mar. 2021. https://pubmed.ncbi.nlm.nih.gov/33804288/. Accessed 4 Jan. 2022.

9. Snyder, Rebecca A. and George J. Chang. "Fiscal Toxicity: A Growing Brunt for Cancer Patients." Bulletin of the American College of Surgeons, ane Sept. 2019. bulletin.facs.org/2019/09/financial-toxicity-a-growing-burden-for-cancer-patients/. Accessed 27 Aug. 2021; "AACR Cancer Disparities Progress Study 2020." American Association for Cancer Research, 2020, cancerprogressreport.aacr.org/disparities/chd20-contents/chd20-disparities-in-cancer-survivorship/. Accessed iv Jan. 2022.

10. Shankaran, Veena et al. "Risk Factors for Financial Hardship in Patients Receiving Adjuvant Chemotherapy for Colon Cancer: A Population-based Exploratory Analysis."Journal of Clinical Oncology, 12 May 2012, pp. 1608-1614. pubmed.ncbi.nlm.nih.gov/22412136/. Accessed 4 January. 2022. ; Shankaran, Veena et al. "S1417CD: A Prospective Multicenter Cooperative Group-Led Written report of Fiscal Hardship in Metastatic Colorectal Cancer Patients." 4 Jan. 2022, https://academic.oup.com/jnci/advance-commodity/doi/10.1093/jnci/djab210/6492636. Accessed 4 Jan. 2022.

11. Narang, Amol K. and Lauren Hersch Nicholas. "Out-of-Pocket Spending and Financial Brunt among Medicare Beneficiaries with Cancer." JAMA Oncology, June 2017, pp. 757-765. world wide web.ncbi.nlm.nih.gov/pmc/articles/PMC5441971/. Accessed iv Jan. 2022.

12. "The Costs of Cancer: 2020 Edition." American Cancer Order Cancer Activity Network, Oct. 2020, p. iv. www.fightcancer.org/sites/default/files/National%20Documents/Costs-of-Cancer-2020-10222020.pdf. Accessed four January. 2022.

13. "AACR Cancer Disparities Progress Report 2020." American Clan for Cancer Enquiry, 2020. cancerprogressreport.aacr.org/disparities/chd20-contents/chd20-disparities-in-cancer-survivorship/. Accessed 4 January. 2022.

14. Wheeler, Stephanie B., et al. "Financial Impact of Breast Cancer in Black Versus White Women." Journal of Clinical Oncology, 10 June 2018, pp. 1695-1701, ascopubs.org/doi/full/ten.1200/JCO.2017.77.6310. Accessed 4 Jan. 2022.

15. Siegel, Rebecca Fifty. et al. "Cancer Statistics, 2021." CA: A Cancer Periodical for Clinicians, American Cancer Society, 12 January. 2021, acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21654. Accessed iv Jan. 2022.

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