Healthcare Reform and Its Effects on Cancer Care
Supreme Court Decision on the Affordable Care Act
On June 28, 2012, the Supreme Court upheld the central component of the Patient Protection and Affordable Care Act agreeing that the requirement for nearly all Americans to secure health insurance is permissible. The vote came down to a 5-4 decision, with Chief Justice John Roberts providing the swing vote for the majority.
ACCC's conference call on the Affordable Care Act is available to members only, and can be accessed here. Log on to ACCC Members-only website; click on Member Resources.
Read our blog about the issue.
Affordable Care Act and Clinical Trials
Section 10103(c) of PPACA added a new provision to the federal Public Health Service Act which imposes requirements on group health plans and health insurance issuers offering individual or group health insurance products to provide for coverage of routine patient costs associated with approved clinical trials.
ACCC members can view a slide show (61 slides) of major provisions of the new law. You'll need to log into ACCC's Members-only website and then click on the Member Content button at left. You will also be able to listen to a recording of a conference call about healthcare reform.
Accountable Care Organizations
On December 3, 2010, ACCC submitted comments to CMS about accountable care organizations.
On June 2, 2011, ACCC submitted comments to CMS about the proposed rule on accountable care organizations.
Here is a list of accountable care organization resources from CMS.
- “Accountable Care Organizations: What Providers Need to Know,” Fact Sheet, ICN 907406. This fact sheet includes a definition of an ACO, and information on how to participate in an ACO, how shared savings will work, how this program is aligned with other quality initiatives and how ACOs help doctors coordinate care.
- “Improving Quality of Care for Medicare Patients: Accountable Care Organizations,” Fact Sheet, ICN 907407. This fact sheet includes a table of quality measures under the program.
- “Advance Payment Accountable Care Organization (ACO) Model,” Fact Sheet, ICN 907403. This fact sheet includes a summary of the Advance Payment ACO Model, background, and information on the structure of payments, recoupment of advance payments, eligibility, and the application process.
- “Medicare Shared Savings Program and Rural Providers,” Fact Sheet, ICN 907408. This fact sheet includes information on federally qualified health centers, rural health clinics, critical access hospitals and how this program impacts them.
- “Summary of Final Rule Provisions for Accountable Care Organizations under the Medicare Shared Savings Program,” Fact Sheet, ICN 907404. This fact sheet includes background, information on how ACOs impact beneficiaries, eligibility requirements to form an ACO, and information on monitoring and tying payment to improved care at lower costs.
- “Methodology for Determining Shared Savings and Losses under the Medicare Shared Savings Program,” Fact Sheet, ICN 907405. This fact sheet includes an overview of the program, a description of the two tracks providers can choose, and a description of how Medicare determines the shared savings or loss.
Here are brief highlights of the Patient Protection and Affordable Care Act:
- Patients/survivors with existing insurance will have more adequate coverage, e.g., no lifetime limits, fewer annual limits, no rescissions, retiree reinsurance, first dollar coverage of screenings and other preventive services
- More insurance options available for cancer patients and survivors
- Subsidized high-risk pools at age adjusted standard premiums
- Access to parents’ plans for dependents up to 26
- Improved information about value of available options; more standardized information
- Some pressure on insurers to keep premium increases more moderate; minimum loss ratios and rate reviews
- Insurance will be available regardless of health status; guaranteed issue and renewability; adjusted community rating; no pre-existing condition exclusions for adults and children
- Insurance may be more affordable (Expanded Medicaid eligibility, private insurance premium and cost-sharing subsidies for those below 400 percent of the federal poverty level, exchanges that will provide for more affordable and accountable insurance options)
- Insurers have to compete more on basis of price and service than on risk selection
- Insurance may be more adequate, especially in individual and small group markets (essential benefit packages meeting defined actuarial values, first dollar coverage of preventive services)
- Some potential challenges and drawbacks: Some may still find insurance unaffordable especially if costs not contained much; state-based exchanges may be too small to create sustainable risk pools and states may not provide aggressive oversight needed to ensure fair competition; employer wellness incentive programs may penalize employees for poor health status
- Beginning in FY 2013, 1 percent of hospitals' base DRG payments are set aside for VBP program, with payments based on performance in 2012 (excludes IME, DSH, outliers, special rural payments; phases up to 2 percent in FY 2017 and thereafter
- Initial measures are ones currently reported, including patient perception of care
- Beginning 2013, outcome measured to be risk-adjusted and all measures endorsed by NQF (with possible exception); beginning 2014, efficiency measures to be added, including spending per beneficiary
- VBP payments are based on performance measured by a single composite score; adjustment is applied to all DRGs
- VBP payments are determined by performance against standards established in advance by the Secretary, no VBP payment for hospitals below minimum threshold
- Program is budget neutral: all incentive pool funds must be paid out to hospitals in year they are withheld
- Quality Reporting: Makes Physician Quality Incentive Program (PQRI) permanent
- Provides 1 percent bonus in 2011 based on successful reporting in designated period and provides a bonus of 0.5 percent in 2012-2014
- Imposes 1.5 percent penalty in 2015 for failure to report successfully; penalty increased to 2 percent in subsequent years
- Beginning in 2011, allows registry reporting through a Maintenance of Certification program operated by a specialty body of the Board of Medical Specialties
- Provides an additional 0.5 percent in 2011-2014 for participation in qualified specialty Maintenance of Certification (MOC) programs
- Requires timely feedback on likelihood of receiving incentive payment and an appeals process
- Requires plan from Secretary to integrate clinical reporting with electronic health records (EHR)
- Physician Feedback Program: Requires confidential feedback reports to physicians comparing their performance on quality and efficiency to peers
- VBP for Physicians: Adjusts 1 percent of physician payment based on value index (quality and efficiency) beginning 2015
- Requires that a hospital complete a community needs assessment once every three years
- Requires hospitals to adopt and publicize a financial assistance policy
- Prohibits billing patients who qualify for financial assistance the top rates
- Prohibits a hospital from taking extraordinary collection actions if the hospital has not made reasonable efforts to notify patients of its financial assistance policy
- 2010 Physician Fee Schedule Final Rule reduces payment for services that require the use of “expensive” equipment (>$1 million) by increasing the equipment utilization assumption in the practice portion of the physician fee schedule from 50 to 90 percent over 4 years; redistributes savings to other services such as primary care; final rule exempts therapeutic services and applies only to MRI and CT
- Health Reform: beginning 1/1/2011, sets the equipment utilization assumption equal to 75 percent for expensive equipment (>$1 million); beginning in 7/1/2010, increases the multiple imaging discount for certain procedures involving contiguous body parts from 25 to 50 percent; excludes reduced expenditures from calculation of budget neutrality