Roundtable: the ACA and Cancer Care

ONCOLOGY’s Editorial Board Members Share Their First Impressions

In few medical specialties have the issues of rising healthcare costs and severe personal hardship resulting from lack of health insurance been seen in such stark relief as they have been in oncology. Both of these issues were among the foremost that the Patient Protection and Affordable Care Act (ACA) was designed to address. Thus, we were eager to hear what the oncologists on our Editorial Board thought of the ACA’s potential for remedying these problems.

Shortly after the rollout of the new healthcare exchanges on October 1, 2013, we asked the members of ONCOLOGY’s Editorial Board to share their impressions of what they were seeing-and what they expected to see-in terms of the effects of the ACA on practicing oncologists and their patients. We asked them to respond to four questions:

1. Are you participating in the exchanges?

2. How much do you think the new exchange health plans will affect physician reimbursement, and how will they affect physicians’ workloads-administrative and otherwise?

3. An influx of new patients presenting with more advanced disease is predicted (those with insurance for the first time). What will this mean in the world of oncology?

4. The ACA has a number of provisions designed to benefit people with cancer-such as the inability of insurers to deny coverage because of a pre-existing diagnosis or to drop a person because of a costly illness or clinical trial participation. Do you think the law ultimately will result in improved outcomes for cancer patients?

Selections from Board Members’ responses follow.

Are you participating in the exchanges?

Some respondents answered “yes”-frequently adding the comment that their institution accepted all patients regardless of their insurance status. Others said that they weren’t sure. One respondent, Nora Janjan, answered “especially given the demonstrated problems in the healthcare insurance exchange sign-up process, thankfully not yet.”

How much do you think the new exchange health plans will affect physician reimbursement, and how will they affect physicians’ workloads-administrative and otherwise?

JAMES B. YU: If my department loses money due to reduced reimbursement or due to inability to obtain insurance certification for radiation therapy, it will impact our future technology upgrades, our ability to hire promising faculty, and our ability to support groundbreaking research. With regard to my workload, I do think the number of precertification forms I need to fill out and peer-to-peer phone calls I need to make in order to get insurance precertification for radiation treatment will increase.

JUDD MOUL: I expect our workload may stay generally stable in my area of urology-but eventually, the copays and patient out-of-pocket expenses will go up for doctor visits to specialists like me. For the serious conditions I deal with, such as prostate cancer, it may not have a huge impact, but for more elective visits, patients may choose not to be seen if they have to pay more out of pocket. Office visits for erectile dysfunction, BPH, and elevated PSA may go down as patients make more choices when they have more out-of-pocket costs at stake.

NORA JANJAN: The ACA decreases Medicare funding by $700 billion at a time when the Baby Boomer population is entering the Medicare system in large numbers. Since the majority of cancer patients are of Medicare age, this cut in Medicare is substantial.

Physician administrative workload is already increased with the more extensive documentation required under Meaningful Use. Administra­tive costs already account for more than 25% of all healthcare costs. I participated in a CMS conference regarding the rollout of Part 2 of Meaningful Use requirements. The HHS staff demonstrated a substantial burden for physician documentation that will only continue to increase. Confirming that Meaningful Use requirements do not apply to patients with private insurance, CMS reluctantly acknowledged the disincentive for physicians to treat Medicare/Medicaid patients. In some locations, up to 20% of physicians have refused to accept Medicare/Medicaid patients within their practice in response to the high administrative burden and low reimbursement that result in a financial loss for each Medicare/Medicaid patient seen.

An influx of new patients presenting with more advanced disease is predicted (those with insurance for the first time). What will this mean in the world of oncology?

MICHAEL GLODÉ: It probably won’t mean much. Patients with advanced disease who can’t see physicians don’t live that long, so I don’t believe there is a big pool of them out there.

CHARLES PENLEY: My personal opinion (and that’s all it is, with no data to support it), is that there will not be a large influx of newly insured patients with advanced disease into the world of oncology. I believe that patients with cancer are currently seeking, and receiving, care. There are diagnostic delays, to be sure, and patients are presenting with more advanced disease, due to the lack of insurance coverage for primary care and screening. When diagnosed, though, the patients seem to be making it into oncology practices.

JUDD MOUL: In my area-prostate cancer-we are starting to see the impact of the backlash against PSA screening already. As more primary care physicians abandon ordering PSA tests, we are seeing fewer referrals for elevated PSA and fewer prostate biopsies. As time goes on, we may migrate back to the pre-PSA era when 20% to 25% of men presented initially with metastases. In addition to this possible reverse stage migration, we will see men who have not had insurance before show up with advanced prostate cancer. Since the treatments for advanced prostate cancer are generally very expensive, this will drive up healthcare costs.

NORA JANJAN: All agree that a program was necessary to assist small businesses that could not take advantage of group rates, and to address the needs of those with pre-existing conditions. However, the insurance plans offered by the ACA exchanges all have significant deductible/out-of-pocket costs that serve as disincentives to the purchase of increasingly expensive health insurance by the average family, as documented by Wharam and colleagues [NEJM October 2, 2013; DOI: 10.1056/NEJMp1309490]. Although the authors advocate for health savings accounts (HSA) to offset high deductibles, the ACA has reduced many of the benefits/incentives for HSAs.

Therefore, the influx of patients with more advanced disease will not be limited to newly insured patients. Instead, the influx of patients with more advanced disease probably will reflect (1) those who do not undergo routine cancer screening because of the high health insurance deductibles imposed by the ACA; (2) those who lost employer-based health insurance coverage and were unable to access/afford exchange-based health insurance, even with a subsidy; and (3) those who chose to pay the penalty as a more cost-efficient option. Finally and most tragically, changes in cancer screening and therapeutic policies may reverse decades of public health education and roll back the advances achieved through early detection and treatment of early-stage disease.

JAMES B. YU: I would be surprised if there were an influx of patients with advanced cancers presenting as a result of the ACA. I think it is more likely that the opposite will likely occur-that in the years to come it is possible that patients will present with earlier stages, since the ACA covers preventative services and screening. I think it would be a fascinating study to perform: to see whether, after controlling for other socioeconomic and environmental factors, patients present at an earlier or later stage in the ACA era due to increased screening and access to primary care.

The ACA has a number of provisions designed to benefit people with cancer-such as the inability of insurers to deny coverage because of a pre-existing diagnosis or to drop a person because of a costly illness or clinical trial participation. Do you think the law ultimately will result in improved outcomes for cancer patients?

JUDD MOUL: Yes, this is a benefit and humane.

JAMES B. YU: Multiple studies have shown that, although many socioeconomic factors impact cancer outcomes, having health insurance is a crucial factor to earlier detection and timely treatment. I do think the law will ultimately improve outcomes.

MELANIE ROYCE: I think that in the areas where access is the main cause of poor outcome, the ACA could significantly have an impact-ie, lead to improvement in outcomes; these are areas like earlier stage of diagnosis for more indolent diseases that can be screened (colon/rectal, prostate, breast, etc) or that can be detected early with routine tests. For highly aggressive tumors, however, access may not be the main reason for poor outcomes, but rather poor biology of the disease. This means then that novel therapies would be needed for improved outcomes. The question then becomes, what is the role of the ACA in promoting the clinical development of new therapies? For instance, is it going to preferentially support clinical trial participation of patients or not?

CHARLES PENLEY: I believe that the law does contain provisions which should ensure that patients with cancer do not lose coverage at a time when they desperately need it, and that cancer survivors do not experience discrimination when attempting to obtain coverage. We will see how this plays out over time, but on the face of it these would seem to be positive changes.

One additional thought: If some of the lower-tiered plans have very high copays for pharmaceuticals, this could be very problematic. With the cost of antineoplastics-oral and intravenous-being what it is, even insured patients could have significant financial barriers to therapy. Currently, uninsured patients do typically receive care, and we are able to obtain drugs through indigent programs or with the help of foundations. We’re simply not sure whether pharma will assist insured (but underinsured) individuals or not.

MICHAEL GLODÉ: Yes, the ACA will result in improved outcomes-particularly if combined with some incentives to have palliative care consults early in the course of disease and less chemotherapy at the end of life, a proven technique for increased survival.

NORA JANJAN: These are important provisions for the cancer patient and for most patients with chronic illnesses. However, what remains to be seen is what level of healthcare coverage will be provided by the exchange health insurance policies, with their bronze, silver and gold options. Having such a three-tiered system will probably perpetuate health disparities based on ability to pay.

Additionally, the substantial additional taxes on those with the so-called “Cadillac” plans with low deductibles and comprehensive coverage will result in many becoming “under-insured” instead of continuing their current comprehensive coverage. According to the Kaiser Health News [Jenny Gold; Mar 18, 2010; http://www.kaiserhealthnews.org/stories/2009/september/22/cadillac-health-explainer-npr.aspx], the ACA defines a “Cadillac” plan as having a yearly cost of $10,200 for an individual or $27,500 for a family, including vision and dental benefits. Such a definition encompasses approximately 19% of insured workers, according to the Congressional Budget Office, and represents a much higher percentage of union employees who have negotiated healthcare plans. Under the ACA, a 40% tax is imposed on insurers on the amount of premiums above the thresholds. Although the tax is levied on the insurer, the cost of the tax will ultimately work its way down to consumers in the form of higher healthcare insurance premiums.

While well-intentioned in theory, the ACA has significant consequences that could adversely affect the diagnosis of cancer and the delivery of cancer care.

Other Comments

JAMES B. YU: Rather than the healthcare exchanges, to me the most concerning part of the ACA is the move towards accountable care organizations (ACOs). Although hopefully this fundamental reorganization of care will mean more evidence-based healthcare delivery, we need to watch closely how ACOs impact cancer treatments such as radiotherapy, where the initial cost of treatment is high but the potential downstream costs in later phases of care may be lower. We need to be careful that “accountable care organization” does not become synonymous with “providing the cheapest initial treatment possible regardless of long-term impact,” and that ACOs are not dominated by primary care physicians or hospital administrators who don’t understand the complexities of modern cancer care. If we can do this, if we can maintain clinical equipoise in the face of fiscal pressures, approaching cancer treatment reimbursement in a thoughtful and evidence-based manner will be beneficial, particularly since the current system is unsustainable.

CHARLES PENLEY: As with most new programs, there are sure to be missteps, and some will try to manipulate the rules to their advantage. Over time, my hope is that these problems will be identified and corrected.