Affordable Care Act implementation looms amid hope, speculation

A great deal of uncertainty exists about what will happen to the US health care system when the Affordable Care Act takes full effect on 
Jan. 1.

The legislation’s broad objectives — establishing near-universal coverage, making quality health insurance more affordable, improving the value of health care and increasing the availability of services, all while making the system more transparent — are relatively straightforward.

The details encompassed in the final 906-page legislation, however, are another matter, sparking intense debate between those who laud the legislation’s comprehensiveness against those who claim the measure is unnecessarily confusing.

Candace Johnson, PhD, deputy director of Roswell Park Cancer Institute, said the complexity of the Affordable Care Act could create uncertainty among clinicians. 

Candace Johnson, PhD, deputy director of Roswell Park Cancer Institute, said the complexity of the Affordable Care Act could create uncertainty among clinicians.

Source: Photo courtesy of Roswell Park Cancer Institute

Candace Johnson, PhD, deputy director of Roswell Park Cancer Institute, lauded the effort to expand access to care to several million more Americans, but she said the law’s complexity could lead to uncertainty among clinicians.

“There are no strict guidelines for what we are supposed to do with it once it goes into effect,” Johnson said in an interview. “It presents quite a task for all of us. We have to hope that there will be more definition surrounding it as the date [of full implementation] nears.”

HemOnc Today spoke with several leaders in the hematology and oncology communities about the potential ramifications of several aspects of the Affordable Care Act (ACA), including the transition from a fee-for-service structure to a fee-for-value model, the transfer of risk from insurance companies to health care providers, how the political controversy surrounding the legislation may affect clinical research, and whether the law will result in a reduction in health care costs.

A broken system

The clinicians who spoke to HemOnc Today for this story shared at least one common viewpoint: A broken system needed to be fixed.

“Health care reform is necessary, regardless of the specific plan,” Barry S. Rosen, MD, FACS, attending surgeon and vice president of medical management at Advocate Good Shepherd Hospital in Barrington, Ill., said in an interview. “We spend almost 20% of our [gross domestic product] toward health care, with a mediocre return on this investment as measured by the overall health of our population.”

“We are paying more than anybody in the world for health care, but we are not getting the highest quality care,” added Johnathan M. Lancaster, MD, PhD, president of Moffitt Medical Group and chair of the department of women’s oncology at Moffitt Cancer Center in Tampa, Fla. “Our outcomes are not comparable to the cost. This is simply not sustainable.”

A fee-for-service model of health care delivery — rather than the fee-for-value model envisioned under the ACA — contributed significantly to skyrocketing costs, said Brian J. Bolwell, MD, FACP, chairman of Cleveland Clinic’s Taussig Cancer Institute.

“Governmental spending on health care is so out of control that it is putting the economic health of the entire country in jeopardy,” Bolwell told HemOnc 
Today. “Central to the ACA is that incentives for payment right now are skewed. There is no disincentive for ordering unnecessary tests. There is no disincentive for not being frugal or thoughtful about what one is ordering. We have to start thinking differently in the cancer field.”

Catalyst for improvement

Approximately 25 million Americans are expected to purchase coverage through health insurance exchanges created by the ACA, and the number of Medicaid beneficiaries is expected to increase by 12 million during the next decade, according to a report by Hutchins and colleagues in the Journal of Oncology Practice.

Sandra M. Swain, MD 

Sandra M. Swain

“In addition to its overarching goal of extending access to millions of uninsured Americans, the new law has been a catalyst for improving care coordination and quality,” said Sandra M. Swain, MD, FACP, ASCO’s immediate past president, medical director of MedStar Washington Hospital Center’s Washington Cancer Institute and professor of medicine at Georgetown University. “The health reform law lays out a national strategy to improve quality that includes creating new ways to develop quality measures for reporting to federal programs and mechanisms for public input.”

Swain highlighted a change to the Physician Quality Reporting System, designed to provide an incentive payment to eligible professionals who satisfactorily report data on quality measures related to services provided to Medicare beneficiaries. Participation will remain voluntary through 2014, but the ACA calls for payment reductions for Medicare providers who do not submit quality data starting in 2015.

“The removal of lifetime caps on insurance coverage is also a step forward for patients with cancer,” Swain added. “Many cancer patients who need repeated courses of treatment can easily exceed their caps and find that they are unable to afford needed treatment and medication. Annual dollar limits on coverage will be tightly restricted for most plans and will be eliminated altogether in 2014. Patients will no longer have to put off treatments waiting for the new plan year to start.”

Swain also lauded provisions intended to ensure coverage of routine costs for individuals enrolled on clinical trials, as well as those designed to prevent insurance companies from denying individuals coverage if they have pre-existing conditions or develop cancer.

Another key component of the legislation is support for preventive services, according to Beverly Moy, MD, MPH, clinical director of breast oncology at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School.

“If the ACA were carried out as intended, millions of Americans would have access to preventive care — such as screening mammography and colonoscopy — without co-pays,” she said. “These have been proven to save lives.”

Far from perfect

The ACA has the potential to improve the US health care system and the lives of cancer patients, but Moy and others have said that the legislation is not perfect.

Beverly Moy, MD, MPH 

Beverly Moy

“Because the Supreme Court has ruled that states are not obligated to expand Medicaid, some states have not opted in,” Moy said. “These are also the states with the poorest, most vulnerable Americans. Given the loss of DHS payments and other factors, that means that health disparities will be exacerbated post-ACA. That was not the intent of this law.”

In June, more than 50 health organizations — including ASCO, ASH and the Oncology Nursing Society — signed a letter urging the Department of Health and Human Services and the Department of Labor to issue additional guidance or regulations to ensure implementation of provisions that prohibit insurers from dropping coverage of individuals who participate in clinical trials, and from denying coverage for routine care individuals would otherwise receive just because they are enrolled on a clinical trial.

“We remain very concerned that implementation of this provision will be very uneven across the country and many consumers may be denied a new protection they should be guaranteed under the law,” the letter reads.

On its website, the Department of Labor — which is responsible for implementing certain provisions of the ACA — said the federal agencies consider the statutory language “self-implementing,” and that group health plans and health insurance issuers “are expected to implement the requirements ... using a good-faith, reasonable interpretation of the law.”

ASCO also was “deeply disappointed” that the ACA failed to address the flawed sustainable growth rate (SGR) formula, Swain said.

“Now exacerbated by the cuts from sequestration, oncology practices are having to make tough choices when it comes to their practices and the Medicare patients they serve,” Swain said. “The temporary, roller-coaster environment of SGR patches continues to remain a faulty solution.”

A proposed Medicare benefit that encouraged and reimbursed end-of-life discussions for patients also failed to make the final legislation.

“Studies have shown this conversation is critical at improving patient quality at the end of life, and ASCO continues to urge Congress to reassess this important component of cancer care,” Swain said.

Harry S. Jacob, MD, FRCPath(Hon)

Harry S. Jacob, MD, FRCPath(Hon)

  • Beyond the scope of this article is an explanation of why it costs approximately 30% more per capita for health care in this country compared with other developed nations, whose entire populations are covered, while 40 million or so US citizens are vulnerable to uninsured catastrophic illness. Moreover, an exploration of the effects of sequestration on academic medicine will be (tearfully) eye-opening in the near future.

    • Harry S. Jacob, MD, FRCPath(Hon)
    • HemOnc Today Chief Medical Editor
  • Disclosures: Jacob reports no relevant financial disclosures.
Alan Lichtin, MD

Alan Lichtin, MD

  • The Affordable Care Act (ACA) will go into effect on Jan. 1, 2014, with a provision (section 2709) that prohibits insurers from dropping or denying routine care coverage for patients participating in approved clinical trials.

    The American Society of Hematology (ASH) and many other groups support this provision because it removes the barrier to entry for patients who may benefit from participating in clinical trials and supports advancements in medical research.

    Although ASH supports this provision, the absence of federal regulations or guidelines that would better ensure providers will equally uphold this section of the law is problematic. The Departments of Health and Human Services and Labor, which are leading ACA implementation, have indicated they will not issue guidelines on this provision, stating that health plans and insurance issuers are expected to implement the provision "using a good faith, reasonable interpretation of the law."

    ASH believes the absence of guidelines or regulations may lead to uneven nationwide application of the law.

    To understand the need for guidelines, consider the difficulty patients enrolled in clinical trials experience in obtaining coverage through Medicare despite the fact that Medicare claims to cover routine clinical trial-associated costs. A study published in Clinical Cancer Research in 2010 further illustrates this, reporting that 80% of Medicare-eligible patients from 2003 to 2008 were denied coverage for routine clinical trial costs even though their coverage indicated otherwise (Klamerus JF. Clin Cancer Res. 2010;16:5997-6003).

    ASH recently joined more than 50 organizations to call for regulations or guidance on the following issues:

    • Clarifying that coverage of routine costs applies to prevention, detection and treatment of complications arising from clinical trials;

    • Guaranteeing the existence of measures allowing patients to use their out-of-network coverage to participate in clinical trials and preventing insurers from requiring patients to travel unreasonable distances to enroll in a clinical trial with an in-network provider;

    • Establishing safeguards to protect patients from delays and administrative barriers that would compromise participation; and

    • Allowing a patient’s health care professional to make the decision as to whether a clinical trial would be appropriate for the patient.

    In the absence of regulations, many patients may be denied a protection that should be guaranteed to them under the law.

    • Alan Lichtin, MD
    • Staff physician, department of hematologic oncology and blood disorders
      Cleveland Clinic’s Taussig Cancer Institute
      Chair, ASH Committee on Government Affairs
  • Disclosures: Lichtin reports no relevant financial disclosures.