I think the Center has made a difference. I have seen, on a case-by-case basis, many women who waited so long to get their breast cancer treated, and we convinced them to get treatment.
—Gina Villani, MD, MPH
It has been a little over a decade since the Institute of Medicine landmark report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care found overwhelming evidence of racial disparities in the U.S. health-care system. Since then, ASCO has been dedicated to minimizing these disparities in cancer care through its Health Disparities Committee, which works to develop programmatic and policy solutions to address these issues and improve outcomes for all populations.
ASCO Connection spoke with Gina Villani, MD, MPH, Chair-Elect of ASCO’s Health Disparities Committee and CEO and Medical Director of the Ralph Lauren Center for Cancer Care and Prevention in New York, a community oncology outpatient facility. As Dr. Villani discusses in this article, disparities in cancer care still very much exist. Following are her experiences with serving the underserved and how she believes the field of oncology can further improve its outreach to these patients.
One Building, Two Levels of Care
When Dr. Villani started out in oncology working at a hospital in New York, she had her own practice and office hours in what she called a “beautiful suite” on one floor and ran a fellows clinic on another. The differences she saw in the behavior toward patients between these two floors was astonishing and not something she’d soon forget.
“It was like I was in a different place,” Dr. Villani said. “The clinic patients would come to the same area to get their chemotherapy as our private practice patients, and they were treated completely differently. I thought, ‘Wait a minute, I’m in the same building and there are two levels of care depending on what your insurance is. I don’t like this.’”
This experience motivated Dr. Villani to get a Master’s degree in public health and dedicate her professional life to working in underserved areas. As CEO of the Ralph Lauren Center, Dr. Villani spent the last 18 months helping to bring the Center back from the brink of financial ruin.
“The Center was in so much financial trouble that if someone didn’t come and turn it around it was going to close down,” she explained. “And I thought, ‘There is no way this Center can close because it’s done so much good for disparities in New York.’ I had to come try to help it.”
The Ralph Lauren Center for Cancer Care and Prevention
Located in the Harlem neighborhood of New York, the majority of patients seen at the Ralph Lauren Center are black or from Hispanic and Asian backgrounds with multiple comorbidities, including diabetes, obesity, and substance abuse. Eighty-five percent are Medicaid- or Medicaid-managed patients. The other 15% are uninsured or think they are; the Center is usually able to help half of that 15% obtain health insurance coverage.
“It’s a struggle to make ends meet because you’re providing a service and barely getting paid for it,” Dr. Villani explained. “We’re providing enhanced services, too. We have a food pantry, and people are leaving here with bags of groceries. We give them MetroCards. It’s what we have to do to build trust and get them to come back.”
In her brief tenure, Dr. Villani has reduced the Center’s $2.5 million deficit by $1.4 million. She has also conducted outreach to primary care doctors in the area, educating them on how to best handle uninsured patients with cancer.
“Primary care is well organized until a patient is diagnosed with cancer,” Dr. Villani said. “The doctor often tells these patients to just go to the hospital. But maybe that’s not the best way to do it. Maybe patients get a bit lost when they go to the hospital. Maybe they aren’t getting timely treatment and have a hard time navigating the system.”
This outreach has tripled the number of patients the Center sees, but has not negatively affected the care the Center provides. Unlike most facilities in the Manhattan area, the Center guarantees a next-day appointment for anyone who calls and says they have a cancer diagnosis. The patient may not be able to have a full medical assessment during that appointment, but they are able to tour the facility and meet with a nurse navigator who will ultimately guide them through the entire treatment process.
With a 40% no-show rate across the board with these patients, getting them in as soon as possible is extremely important to building trust in the system. And because the system has failed so many of these patients, building trust can be challenging.
“I think in medicine in general, we are very quick to blame the patient, especially in this population,” Dr. Villani said. “There is a level of distrust, and there is a reason for that distrust. I once worked in a place where the minute you walked in the door, the first person you saw was a uniformed security officer who was never very nice. You walk through the hospital, and it’s not clean and it’s not inviting, and then you meet a doctor who doesn’t spend time and doesn’t treat you nicely. Are you really looking to go back to that?”
One of the first action items Dr. Villani had when she became CEO of the Center was to conduct a “secret shopper” experiment. She wanted to see how long it took a Medicaid-managed patient with stage IV lung cancer to be seen at one of the area hospitals.
“I had one of our employees pose as the son of this patient and call 10 different hospitals in Manhattan and the Bronx, looking for an appointment for a medical oncologist for his father with lung cancer,” she explained. “We recorded how many times he got transferred on the phone, what it took to get to a person, what was the wait time, when was that appointment being made, and where was his father going to be seen. We set up a grid of these 10 different hospitals, and what we found was really scary. Our longest wait time was 53 days. And the next one was 35 days. Among these 10 hospitals, the best we could do—and that was our outlier—was to see the patient in a week.”
The problem, Dr. Villani believes, is in the reimbursements. “I think the truth of the matter is if you’re going to have a patient reimburse you $300 vs $40, you’re going to get those $300 people in first. It’s just reality,” she said.
“I think the Center has made a difference,” Dr. Villani said. “I have seen, on a case-by-case basis, many women who waited so long to get their breast cancer treated, and we convinced them to get treatment. We have many stories of people who didn’t have the right treatment, and we’ve tried to fix that. These patients are so nice and so grateful and have had so many hard knocks in life. What keeps me going are these nice, grateful people. They have a lot of humility.
ASCO’s Health Disparities Efforts
ASCO is committed to educating its membership about disparities in cancer care. For example, ASCO is working on a series of patient education videos about common barriers to receiving quality cancer care, as well as how to navigate these challenges. The videos, funded by the LIVESTRONG Foundation, will be available soon on Cancer.Net. Furthermore, ASCO University® has partnered with the LIVESTRONG Foundation and 11 other organizations to create an
eLearning Series comprised of three courses focusing on disparities in cancer care. (see sidebar on page 54 for the full list of partnering organizations). The courses are:
Disparities in Cancer Care: Take Action!—which includes an overview of perspectives from a care provider, an institution providing care, and a patient
Cultural Competence for Oncology Practice—which examines three different patients with similar clinical issues, but from diverse backgrounds
Disparities in Cancer Care: Do You Know…?—a multiple-choice self-assessment that allows participants to assess their knowledge and understanding of issues relating to disparities in cancer care
These eLearning courses, funded by the LIVESTRONG Foundation, include audio commentary, slides, and links to references and resources. Visit university.asco.org/disparities for more information.
Originally printed in ASCO Connection. © American Society of Clinical Oncology. “Serving the Underserved: Dr. Gina Villani and ASCO’s Health Disparities Committee Work to Minimize Cancer Care Gaps.” ASCO Connection, January 2013: p. 30. All rights reserved.