Grappling With Healthcare Upheaval

Donna E. Shalala, PhD

Oncology leaders are bracing for a host of changes in the healthcare system, not only as a result of the recently upheld insurance reform legislation but also because of continued pressure to control the ever-rising cost of cancer care.

Against this backdrop, Donna E. Shalala, PhD, a former US Secretary of Health and Human Services, is scheduled to open Saturday’s session of the 30th Annual Miami Breast Cancer Conference with a presentation on trends affecting physicians and their patients.

Shalala, who served in President Bill Clinton’s administration, has been president of the University of Miami since 2001. She is a well-known voice in the national conversation about the state of American healthcare, and has shared her opinions about issues including t he Affordable Care Act (ACA), which has significant implications for the oncology community.

Under the ACA, individuals must buy their own insurance if they are not covered through an employer or government program, and are not otherwise exempt from the rule. Starting in 2014, the penalty for not complying will be a “shared responsibility payment,” or tax, payable to the federal government.

Shalala has said she suppor ts the act as a system in which all Americans will share the cost of health insurance. “We need universal coverage so that we share costs and spread risk over larger and larger numbers of people,” Shalala said during a September 2012 panel discussion about the ACA at the University of Miami. She said t hat many Americans are without coverage because they have lost their jobs or were not insured by their employers to begin with, and that, as a result, the rest of the population is absorbing their healthcare costs.

Congress enacted the ACA in 2010 to increase the number of Americans covered by health insurance and decrease the cost of healthcare, but the act was challenged by 26 states, several individuals, and the National Federation of Independent Business. In their lawsuit, the parties argued that the plan was a costly, unconstitutional usurpation of individual rights. However, the US Supreme Court decided in June 2012 to uphold most tenets of the legislation.

While Shalala said that the ACA will help level the playing field in a “fragmented” healthcare system that provides government coverage for some, divergent levels of private coverage for others, and no coverage for many, she acknowledged that its passage will raise new complications. Perhaps the broadest concern, she said, is determining the government’s ideal role in providing healthcare.

“Should the federal government make certain that every American has health insurance through a regulatory system, a subsidy system, or leave it to the states— throw money at them and let them design it?” she asked during the panel discussion.

With the ACA in place, she added, American leader s will have to figure out how to contain healthcare costs, a contentious issue that will be far more difficult to resolve than the problem of arranging universal coverage.

Promise and Peril in New Law

“President Obama was able to get the coverage piece done because it’s putting a trillion dollar s of new money into the system, but getting the deal and the votes on cost containment, given the stakeholders—the whole healthcare system and their lobbyists—is much more complicated and requires bipartisan consensus,” she said.Like Shalala, leaders in the oncology care and research communities have applauded the potential of the new law to expand access to healthcare but mixed their optimism with a measure of caution over the impact of the legislation.

The American Society of Clinical Oncology (ASC O), the American Cancer Society, and the American Association for Cancer Research were among the organizations that supported the Supreme Court’s decision to uphold the law.

Provisions expected to help patients include free preventive screenings, the elimination of lifetime limits within health insurance plans, and the opportunity for people to get private health insurance regardless of pre-existing conditions. Fears include cost controls that result in the rationing of care and bureaucratic intrusion into decision-making.

Moy et al discussed the anticipated effects of the ACA on the oncology community in an ar ticle that appeared in the 2012 Educational Book that the ASCO published in June at its annual meeting.¹

The ACA holds promise, the authors wrote, because it will help close the Medicare “donut hole” gap in prescription drug coverage, important for those taking expensive oral cancer therapies; it will no longer require children who want hospice services to forgo curative services; it gives patients the right to a timely external appeal of coverage decisions; and it prevents insurers from denying coverage for clinical trial costs, which could ultimately increase minority participation in trials.

At the same time, the authors expressed concerns about the law, including a potential decrease in oncology provider participation in Medicaid as reimbursement levels drop; continued poor cancer outcomes among Medicaid patients; and the lack of a mandate for insurers to cover follow-up testing of abnormalities found in cancer screenings.

Cancer Spending Under Scrutiny

In addition, oncologists are likely to face ethical challenges as a result of attempts to control costs through new practice models such as accountable care organizations, the authors noted. “Not only is the entire success of this experiment in expanded healthcare coverage dependent on financial sustainability, but oncologists are likely to directly feel the impact of any ongoing failure to shift the cost curve,” they said.Beyond the new healthcare law, oncology leaders are expressing concerns about potential changes in federal payment programs, particularly the Medicare reimbursement structure. In January, ASCO launched a stepped-up advocacy effort that includes an increased presence on Capitol Hill and building bridges with other medical associations. In addition, the organization published a four-part series of issues briefs on its “ASCO in Action” web page.²

The cost issues, as ASCO described in its January 27 brief, are stark: Healthcare spending that is outpacing the rate of economic growth has helped fuel a soaring national debt and, although cancer care costs represent only about 5% of total healthcare costs, oncology is the fastest-growing category of expenses, rising 15% to 18% annually. Legislative solutions, however, may exacerbate economic pressures and quality of care both for patients and providers, ASCO leaders assert. With more than 60% of cancer diagnosed in patients who ar e Medicare beneficiaries and the population of older people on t he rise, changes in the payment structure of that program are of particular concern.

Specifically, ASCO leaders are worried about the future of three areas: the Medicare sustainable growth rate (SGR) formula, which links physician payments to the nation’s gross domestic product and has been problematic since the economy slowed in 2002; chemotherapy drug reimbursement or the “buy and bill” system; and fee-for-service Medicare payment options.

“For the most part, potential savings will come on the backs of healthcare providers,” the ASCO brief said, but patients will feel its effects in increasing insurance premiums, deductibles, copays, prior authorizations, and tiered formulas.

Milestones in the Affordable Care Act

March 23, 2010: President Barack Obama signs the Affordable Care Act, paving the way for healthcare reform that will be instituted over the next 4 years.

July 1, 2010: A temporary, national health insurance plan is established for people who have been uninsured 6 months or longer because they have a pre-existing condition. September 23, 2010:

• All new health insurance plans are now required to provide preventive services, such as mammograms and colonoscopies, without charging patients a copay, deductible, or coinsurance.
• Insurance companies can no longer deny coverage to sick people based on retroactive inspections of their application documents that reveal mistakes or technical errors. Some insurers had used this practice to revoke the coverage of patients after they got breast cancer.
• Insurance companies are no longer allowed to impose lifetime limits on the essential benefits in their health plans, such as hospitalization.
• Children under 19 can no longer be denied health insurance because of pre-existing conditions.

2010: A $15 billion Prevention and Public Health Fund is established to promote healthy habits through programs such as smoking cessation and obesity reduction.

January 1, 2011: Seniors on Medicare are now entitled to free preventive services, including wellness visits and personalized prevention plans. High-risk seniors who have been hospitalized will receive help in avoiding readmission through a Community Care Transitions Program.

March 2012: In order to help identify and reduce disparities in healthcare among people of different races and ethnicities, ongoing and new federal health programs must now collect and report racial, ethnic, and language data.

January 1, 2014:

• Health insurers can no longer drop or limit coverage for patients who participate in clinical trials, including those that treat patients who have cancer.
• Health insurers can no longer impose annual coverage limits on people who have new insurance plans or existing group plans.
• Health insurers can no longer deny coverage, or refuse to renew it, due to a patient’s pre-existing condition, and cannot charge more for plans based on gender or health status.
• Americans can now shop for their own health insurance through the Health Insurance Marketplace, which will offer qualified plans in a competitive atmosphere.

US Department of Health & Human Services. What’s changing and when. Available at HealthCare.gov website. www.healthcare.gov/law/timeline/index.html. Accessed February 27, 2013.

References

1. Moy B, Abernethy AP, Peppercorn JM. Core elements of the Patient Protection and Affordable Care Act and their Relevance to the delivery of high-quality cancer care. 2012 Educational Book. 48th Annual Meeting of the American Society of Clinical Oncology; June 1-5, 2012; Chicago, IL. www.asco.org/ASCOv2/Education+%26+Training/ Educational+Book?&vmview=edbk_detail_ view&confID=114&abstractID=192. Accessed February 27.
2. Oncology practice front and center in national payment reform debate. ASCO in Action website. http:// ascoaction.asco.org/Home/tabid/41/articleType/ ArticleView/articleId/417/Oncology-Practice-Frontand- Center-in-National-Payment-Reform-Debate.aspx. Published January 27, 2013. Accessed February 27, 2013.

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