Roxanne Nelson

June 11, 2013

CHICAGO — The Affordable Care Act (ACA), passed in 2010 and still being debated, has led to a series of changes that will undoubtedly affect the way oncology is practiced.

The Act "is a big audacious complex piece of legislation that has been in place now for 3 years, and we still are still learning about the implementation of it," said William Charles Penley, MD, from Tennessee Oncology in Nashville. "The full impact has yet to be realized and it is still politically contentious. I can't pretend to know how this is going to play out."

 
The full impact has yet to be realized and it is still politically contentious.
 

The full impact on patients, coverage, and providers has also yet to be realized, said Dr. Penley, who chaired a session on the impact of the ACA on the practicing oncologist here at the 2013 Annual Meeting of the American Society of Clinical Oncology (ASCO®).

After giving a brief overview of the law and where it currently stands, Dr. Penley pointed out that there are "very few oncology-specific aspects of this law."

"What we know is that cancer survivors can't be denied coverage because of pre-existing illness," said Dr. Penley. "The Medicare Part D donut hole, which is a big factor for our patients who are prescribed expensive oral oncolytics, is supposed to be reduced and eventually eliminated."

In addition, children with cancer can't be denied coverage because of a pre-existing condition, lifetime limits will be eliminated by 2014, and coverage can't be rescinded on the basis of "technicalities," he explained. "There will also be increased access to preventative services, with the goal of decreasing the incidence of these illnesses."

Constant Revision

 
Keeping up with the Affordable Care Act and trying to digest it all is like drinking from a fire hose.
 

There is no doubt that the legislation is complex. "Keeping up with the Affordable Care Act and trying to digest it all is like drinking from a fire hose," said Steven Stranne, MD, JD, who spoke on the panel.

Despite the complexity and the length of the ACA, it is really just a framework, said Dr. Stranne, who is from the law firm of Polsinelli Shughart PC, in Washington, DC. "There are gaps, there are conflicts, there are ambiguities and outright discretion that is granted to the secretary of the different agencies that implement the law."

"That's been playing out over the past 3 years, and that's what has been keeping everybody busy in Washington, just in case you were wondering," Dr. Stranne told attendees.

These laws are "not like the Constitution," which is difficult to amend. Rather, the ACA is going through constant revision; that is the process that is occurring right now, he said.

One of the key points of the ACA is expanded patient access, but even though the law takes effect in 2014, it doesn't mean "that everyone is going to be insured immediately."

An estimated 30 million people will gain access to insurance, 2 million of whom will be enrolled this year. By 2015, it is expected that 20 million will be enrolled, and by 2017, 27 million will be. One of the ways of expanding coverage to the uninsured is through expansion of the Medicaid program, which Dr. Stranne emphasized is up to the individual state, and not a mandate.

Although the ACA relies heavily on Medicaid to expand coverage, some stakeholders are concerned about the adequacy of coverage and reimbursement under this program. "One concern is that the outcomes for cancer patients with Medicaid are not much better than for the uninsured," he said. "But whether or not your patients are going to benefit from this expanded coverage depends on which state you live in."

There are important patient safeguards in the legislation that will affect cancer patients, one of which is the required coverage for routine clinical trials. "This is a great safeguard that has been added to the legislation, and one that will go into effect in 2014. I hope you all are able to take advantage of that with your patients," said Dr. Stranne.

Bending the Cost Curve

"In general, policy makers are hesitant to limit or remove coverage, or use the "r" word — ration — under Medicare expressly on the basis of cost," explained Dr. Stranne.

The Center for Medicare and Medicaid Innovation (CMI), created as part of the Centers for Medicare and Medicaid Services (CMS), has "tremendous authority and discretion to test and implement new payment methods," he said.

The CMI has the authority to test and expand the use of innovative approaches to reimbursement under Medicare without further action by Congress. The emphasis is on integrated care, bundling payment for episodes of care, risk sharing among providers, improved coordination among providers, and the formation of networks.

"Congress has suggested evaluation of treatment planning in cancer care and addressing the gaps in cancer quality that ASCO has been highlighting for some time now," he said. Some of the oncology-focused evaluations underway involve a medical home initiative, palliative care, a radiation program, and comprehensive home care for advanced illness.

Every one of the pilot projects is 3 years long, and the projected savings exceed the funding that the federal government is putting into them, Dr. Stranne emphasized.

ASCO Efforts

Dr. Penley noted that although ASCO doesn't have an ACA task force, they have a number of committees and task forces that are working on the care of cancer patients. "There is an oncology service provision that meshes very nicely with some of the components of the ACA," he explained. "We have a very robust quality program."

The Quality Oncology Practice Initiative is now considered a model for specialty quality registries. It is on track to be "deemed" a demonstration of practice quality reporting by the CMS. ASCO's CancerLinQ program is the next step in quality practice, Dr. Penley said, and the prototype is well on the way to successful completion.

He explained that ASCO has developed some "guiding principles of payment reform," which affirm that every patient has access to high-quality, high-value, evidence-based care, and that the wishes and needs of patients are protected through shared decision making with their physicians.

"We are going to support system-wide reforms and improvements that keep pace with the evolution of the healthcare system," Dr. Penley noted. "Things are changing quickly."

"However, ASCO will continue focus on quality, value, access to care, and innovation. I believe those things will position us very well, whatever happens on the political or implementation level," he noted. "We need to stay focused on the patient and the provision of high-quality cancer care."

Dr. Penley and Dr. Stranne have disclosed no relevant financial relationships.

2013 Annual Meeting of the American Society of Clinical Oncology. Presented June 3, 2013.

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