Healthcare Reform and Its Effects on Cancer Care
Health Insurance Marketplaces
On October 1, 2013, state-based health insurance marketplaces (also known as insurance exchanges) open for enrollment. Created under the Affordable Care Act (ACA), the exchanges are designed for the uninsured, people who buy their own coverage, and those whose employer-provided coverage is too expensive or lacks needed benefits.
For people with cancer, a history of cancer, or a risk for cancer, understanding the coverage for cancer-related health services is crucial for making educated decisions based on their healthcare needs and budgets.
The Cancer Insurance Checklist, developed by the Cancer Support Community in partnership with the Association of Community Cancer Centers and 17 other cancer and patient advocacy organizations, is designed to be used while evaluating insurance plans and when discussing them with a navigator or healthcare provider. It offers a checklist, a glossary, and additional resources to help with insurance-related decisions.
Patients and providers can access it at www.cancerinsurancechecklist.org.
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's MyNetwork and click on Advocacy and Policy.
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 MyNetwork. You will also be able to listen to a recording of a conference call about healthcare reform.
Accountable Care Organizations
ACCC Members can listen to the archived conference call of a discussion about the final ACO rule. You'll need to log in to MyNetwork.
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 are brief highlights of the Patient Protection and Affordable Care Act:
Implications of Insurance Reform and Expanded Care for Cancer Care: Near-Term
- 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
Implications of Insurance Reform and Expanded Care for Cancer Care: 2014 and After
- 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
Value-Based Purchasing (VBP) for Inpatient Hospital Services
- 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 and VBP—Physicians
- 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
Payment for Medicare Imaging Services
- 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