May 12, 2010 - 3:52 pm
How Will Cancer Care Fare Under Health Care Reform?
The dust is just settling on the great health care reform debate as legislation has now been signed into law. The Patient Protection and Affordable Care Act of 2009 (H.R. 3590) was passed by the Congress, and then immediately amended by the Health Care and Education Affordability Reconciliation Act of 2010 (H.R. 4872). The President added his signature to make both bills collectively the law of the land, in what will go down for generations to come as the most sweeping reform of the health care system. The burning question on the minds of many providers within oncology is, “How will the law affect patients with cancer and the delivery of care?”
Reform Positives for Patients and the Cure
There are some very positive aspects of the law that should help ease the burden that patients with cancer face in dealing with the cost of treatment. By 2014, insurance companies will be banned from imposing annual and lifetime payment caps, which are frequently an issue for patients being treated for cancer. Also, Americans with a pre-existing condition, such as cancer, who seek to acquire insurance cannot be turned away by insurers. Overall, there will be more transparency for people shopping for insurance, and by 2014, insurance “exchanges” will be available for individuals and small businesses. These reform changes are intended to make the insurance market easier to navigate and more price competitive for the little guys.
Clinical trial testing of cancer drugs of the future received a much-needed boost in the new law. By 2014, insurance companies will be prohibited from stopping patients who have cancer from participating in research and will be required to pay the routine costs of care associated with clinical trials. This is a very important reform that will fuel the next generation of cancer therapy innovation.
Coverage Does Not Equal Care
At first blush, expanding insurance coverage to an additional 32 million Americans appears to be a positive measure. However, approximately half of those individuals will be covered by Medicaid, the government program providing coverage for individuals in monetary need. Even though the federal government will be subsidizing this increase in the Medicaid population, fewer providers participate in Medicaid. As it is now, Medicaid reimburses providers at rates typically less than Medicare does, and as states face mounting recessionary pressures, they are trying to push rates even lower. Recognizing this reality, the law mandates that primary care physicians be paid at Medicare rates when treating patients newly added to the Medicaid program. However, this will not apply to oncologists and other specialists. Thus, a major premise of the law, that “(insurance) coverage equals care,” has been undermined.
Payment Cuts and Delivery System Changes
In an attempt to curb the growing utilization of diagnostic imaging, the law further cuts Medicare payments for MRI, CT, and PET services, which are key tools in diagnosing cancer and managing its treatment. In keeping with the theme of lowered reimbursement, the law creates the Independent Payment Advisory Board, which will be tasked with cutting Medicare spending in years when spending targets are exceeded. This nonelected, 15-member board will essentially take oversight of the Medicare program away from the Congress. The recommendations of the board will be binding, and seemingly very difficult for Congress to overturn. This initiative looks very much like the failed sustainable growth rate (SGR) benchmark that Congress created years ago as an economic base for Medicare payments to physicians—only on steroids. (Provision for any fix or patch to the SGR was removed from the legislation, by the way.)
Physicians have been living with a series of short-term patches intended to avert a 21.2% reimbursement cut; the deadline for a solution from Congress is May 30. Finding the long-term solution will be a challenge, since health care reform is already law, and financial, climate, and immigration reform are the current battles on Capitol Hill. There is indication, however, that Congress is working on legislation that will include a 3-to-5 patch of the SGR, which would keep Medicare payments at current levels or with slight increases annually. We will provide an update on this move in a subsequent report.
One issue that we have not yet covered in these communications is the underlying push to transform the delivery of and payment for health care. The intent of the law is to transition the payment system for providers—including hospitals and physicians—from a model based on the quantity of services to a new model based on the delivery of quality care. That sounds interesting in concept, but translating it to cancer care is a daunting challenge. Treating “cancer” is, in fact, the treatment of numerous diseases, and in a manner that must be individualized based on factors such as age, health status, and comorbidities. Additionally, if you read between the lines of the law, the thrust is to place more risk on providers and to make them active participants in cutting health care costs. We will examine more of these issues, with specific aspects of the new law, in our next update.
Adding More Pressure to a System Already in Distress
The basic problem with the law is that it places more pressures on community oncology clinics already facing unsustainable reimbursement cuts by the government. Ensuring that more Americans have insurance coverage—especially coverage that does not discriminate against or burden patients with cancer—is a step in the right direction. However, simply providing insurance does not guarantee that Americans battling cancer will find quality, accessible care. The law neglected to provide solutions to a cancer care delivery system that is already under pressure. Worse yet, it established provisions that will likely turn up the pressure for oncology providers, in turn adversely affecting patients with cancer. Reports are already increasing of clinic closings and patient displacements, causing issues of access to care. Additional strains on the system will only make a bad situation worse.