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How the Affordable Care Act Has Affected Cancer Care in the United States: Has Value for Cancer Patients Improved?

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How the Affordable Care Act Has Affected Cancer Care in the United States: Has Value for Cancer Patients Improved? PRACTICE MATTERS How the Affordable Care Act Has Affected Cancer Care in the United States: Has Value for Cancer Patients Improved? Stephen M. Schleicher, MD, MBA1, Nancy M. Wood, MS2,3, Seohyun Lee, MA2,3, Thomas W. Feeley, MD2,4 The Patient Protection and Affordable Care Act to 12% today.[5] Although data are anecdotal, (ACA), passed in 2010, contained a number of there is no question that the increased numbers of provisions with potential to directly or indirectly patients with insurance resulted in cancer patients affect cancer care.[1] Value for patients was widely receiving care they previously could not. discussed throughout the bill, and the Centers for ACA provisions prohibit denying coverage or Medicare and Medicaid Services (CMS) indicated charging higher premiums for pre-existing condi- that CMS embraces value as a priority. Nonethe- tions. While few data illustrate the impact of these less, serious questions remain as to whether the provisions, they have momentous implications for ACA has improved the value Americans receive many cancer patients, including pediatric cancer in cancer care. Value in cancer care balances out- survivors, one-third of whom develop a second- comes that matter to patients and the costs in- ary severe or life-threatening condition after their curred to achieve those outcomes.[2] Here we re- treatment has ended.[6] Although data are anecdotal, there is no question that the increased numbers of patients with insurance resulted in cancer patients receiving care they previously could not view the goals of each cancer provision of the ACA Unfortunately, not all effects of the increased and discuss the effects each has had to date. access to insurance under the ACA have been posi- tive. Narrow networks created by some insurers to Access to Cancer Care control costs in response to expanded insurance Highest-value cancer care can only be achieved coverage requirements have limited access to care. if all Americans have access to the best possible Medicare Advantage enrollment has increased cancer care outcomes. A prominent pillar of the from 28% of total Medicare beneficiaries in 2013 ACA is its vision of improving access to healthcare to 31% in 2015.[7,8] Despite the demands of CMS through improved health insurance coverage. The network adequacy criteria, limited provider access legislation authorized development of state and in Medicare Advantage organizations still poses a federal health exchanges, created individual and threat to cancer patients. A recent Government Ac- 1Memorial Sloan Kettering Can- employer mandates, and authorized expansion of countability Office report highlighted uncontrolled cer Center, New York, New York Medicaid. By 2016, 31 states and the District of Co- network formation and undisclosed terminations 2University of Texas MD Ander- lumbia had expanded Medicaid.[3] Thirteen states among Medicare Advantage organizations and rec- son Cancer Center, Houston, created their own exchange; the rest relied on the ommended better oversight of network adequacy Texas federal exchange or used federal and state funding by CMS.[9] Furthermore, federal regulations guid- 3UTHealth School of Public to develop an exchange through partnerships. As a ing each state’s Medicaid managed care organiza- Health, Houston, Texas result of these measures, 16.4 million citizens who tion standards do not address specific metrics for 4Institute for Strategy and Com- were uninsured at the time of ACA enactment had network adequacy, despite the rapid increase in petitiveness, Harvard Business gained health insurance coverage by May 2015,[4] Medicaid managed care enrollment that came with School, Boston, Massachusetts and the uninsured rate declined from 18% in 2013 Medicaid expansion.[10] 468 ONCOLOGY | TheOncologyJournal.com MAY 2016 PRACTICE MATTERS Cancer center exclusion from private insur- ments and value-based purchasing) and to alterna- ance networks was quantitatively demonstrated tive delivery systems (such as accountable care or- in a 2014 survey of 19 nationally recognized com- ganizations [ACOs] and patient-centered medical prehensive cancer centers: only 4 of the surveyed homes [PCMHs]) by 2018.[18] centers were covered in all their state exchange plans.[11] We similarly reported that of the 11 New Reimbursement Models: Bundled stand-alone cancer centers that make up the Al- Payments and Value-Based Payments liance of Dedicated Cancer Centers, two are no Traditional FFS reimbursement is based on the longer covered by local exchange plans.[12] Sev- quantity of services provided without incentive eral of these cancer centers expressed an inability to improve quality or reduce costs. In contrast, As a result to track which of their patients possess exchange bundled payments provide a single payment for plans, impeding study of the impact of the ACA all services related to a specific condition or for of limited on patient access to cancer care. Furthermore, a treatment across a predefined time period—and, coverage 2015 survey shows 9% of employers offering plans ideally, are linked to clinical outcomes, aligning with narrower networks.[13] As a result of limited payment with quality and efficiency. Time periods options, which coverage options, which for the most part are the covered can range from acute hospitalizations to for the most product of cost-reduction strategies, millions of 90 days, as in the upcoming Medicare bundle for cancer patients remain deprived of opportunities knee replacement surgery.[19] Some argue that to part are the for best-quality cancer care at the nation’s leading have the greatest gains in cost savings and quality product of cancer hospitals. improvement, bundles should focus on complex chronic diseases, such as cancer, and should use cost-reduction New Reimbursement and time periods beyond the 3 months allotted in the strategies, Care Delivery Models Medicare joint replacement bundle.[20] Value for cancer patients can be improved tremen- Bundles for cancer care remain in their infancy, millions dously if costs are controlled. Yet, costs of cancer and data on their impact are limited. A published of cancer care delivery are rising, including the costs to in- UnitedHealthcare pilot of five medical oncology dividual patients, due to increased cost sharing, as groups used bundles for breast, lung, and colon patients well as skyrocketing drug prices.[14] Cancer care is cancer across time periods ranging from 4 to 12 remain pricey, with a reported $124 billion of expenditures months, demonstrating significantly decreased annually across all payers at the time of ACA en- costs compared with a national registry of FFS deprived of actment.[15] There are wide variations in the cost patients over similar time periods, with no differ- opportunities of cancer care delivered (the regions that spend the ences in various quality metrics.[21] These positive most on cancer care spend between 32% and 41% results led the insurer to pilot a year-long prospec- for best-quality more than the regions that spend the least), with tive bundled payment for head and neck cancer at cancer care at no relation to survival outcomes,[16] making can- the University of Texas MD Anderson Cancer Cen- cer care a prime target for alternative payment and ter. Preliminary information suggests that revenue the nation’s delivery models. cycle tools currently used for FFS claims manage- leading In an attempt to contain escalating national ment are ineffective at processing bundled pay- healthcare costs, the ACA and CMS established ment claims from both providers and payers.[22] hospitals the Center for Medicare and Medicaid Innova- CMMI’s upcoming Oncology Care Model, in- tion (CMMI) to develop and test new reimburse- troduced as a bundled payment model (although ment and care delivery models. The Secretary of it is not), will use 6-month episodes of care for pa- Health and Human Services has legal authority, tients receiving chemotherapy, combining limited without further congressional approval, to imple- monthly per beneficiary per month allocations ment throughout Medicare any payment mod- with performance-based retrospective payment els that demonstrate savings while maintaining adjustments in an attempt to incentivize high- quality.[17] Subsequently, in January 2015, CMS quality care.[23] Applicants selected for use of this announced its intention to shift payments from model will be notified in late 2016.[24] volume to value through the use of alternative pay- The ACA also specified that value-based pur- ment models, establishing a priority of tying 50% chasing pilot programs be conducted in cancer of traditional fee-for-service (FFS) payments to care by January 1, 2016.[25] Although these pay- new reimbursement models (such as bundled pay- for-performance pilots have not yet been initiated MAY 2016 TheOncologyJournal.com | ONCOLOGY 469 PRACTICE MATTERS by CMS, private insurers are testing pay-for-per- grant to Innovative Oncology Business Solutions to formance in some markets. replicate and scale their oncology-specific PCMH to seven oncology practices nationwide, with early New Care Delivery Models: results suggesting feasibility.[33] ACOs and PCMHs As a delivery model, ACOs encourage integra- Coverage of Clinical Trials tion of care across a population of patients. ACOs Clinical trials are essential for the advancement of also utilize alternative payment models, with capi- cancer treatment, yet there are many barriers to pa- tated payments for patients in the ACO and cost tient enrollment.
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