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By Leah Ralph, <em>Director of Health Policy, ACCC</em>
As we head into the New Year, 2016 is rapidly receding in the rear view mirror. Still, it was quite a year. We saw the Obama Administration finalize regulations for sweeping physician payment reform in Medicare, oncology practices nationwide navigate the first year of the Oncology Care Model (OCM), policymakers try – and fail – to push through drug pricing reform with a national mandatory demonstration program, the 21st Century Cures Act signed into law, and the drug pricing debate hit a fever pitch, fueled by public scrutiny of recent spikes in drug spending and prompting a range of policy proposals to reduce spending on pharmaceuticals, raising bigger questions about how to define value in cancer care.
And after nearly eight years of a healthcare system shifting to achieve the aims – and requirements – of President Obama’s signature health reform law, the surprise election of Donald Trump and transition to a Republican administration and Congress who have prioritized repealing the Affordable Care Act (ACA) in early 2017 – combined with unprecedentedly thin policy prescriptions on the campaign trail – mark the beginning of an uncertain, tumultuous, perhaps even bumpy period for health policy. And fasten your seat belts because it may happen fast: the first 18 months of a new presidency and congress is the most active period of policymaking in the U.S.
ACA’s Uncertain Future
With respect to the ACA, while the health reform law encompasses far more than the insurance exchanges, the public debate to date has been focused on the coverage mandate and subsidies in the individual marketplace. It’s important to note that regardless of the election results, the health insurance exchanges are doing worse than expected. The exchange markets are facing sicker-than-expected risk pools and lower enrollment, causing high premium increases and insurer withdrawals. To survive, the exchanges would have needed stabilization under any administration – meaning a Trump Administration could simply leave the exchanges untouched and effectively allow them to wither on the vine, leaving 20 million uninsured.
But President-Elect Trump has signaled that he favors politically popular consumer protections in the ACA, such as banning insurers from discriminating against people with pre-existing conditions and allowing children to remain on their parents’ health plan until age 26. However the path to achieve this without a requirement that individuals either obtain coverage or pay a penalty remains unclear. And while there’s no agreed-upon replacement plan, Congressional Republicans have also supported allowing the sale of health insurance across state lines, expanding the use of health savings accounts (HSAs), replacing the ACA’s health insurance subsidies with tax credits, and establishing high-risk pools. But none of these proposals would meaningfully restore access to insurance coverage for the more than 20 million people who have gained coverage under the ACA, creating a long road ahead to find ways to cover this newly expanded population in any replacement plan.
What will these changes mean for cancer patients and providers? While the scope and details remain unclear, generally, under the proposals put forward to date, cancer providers may see an increased number of patients who are under- or uninsured, and higher uncompensated care costs. For the exchange population, benefits and cost-sharing assistance will likely be less generous, which could pose significant access barriers to quality cancer care. At the same time it’s important to note that the ACA overpromised and underperformed – while patients without access to subsidies are seeing out-of-pocket costs spike, concurrently providers’ expectations of gaining fully insured patients under the ACA have not necessarily been realized. Patients with exchange coverage have generally been sicker and more expensive to treat and, on top of that, some providers are starting to see their Disproportionate Share Hospital (DSH) payments evaporate, as agreed to under the law. Fixes to the ACA – beyond what Republicans are proposing – are needed to shore up the long-term viability of our healthcare system for both patients and providers.
The Path Ahead
As the New Year rings in the changes in Washington, D.C., there will undoubtedly be significant impact on the direction of federal policy with respect to access and coverage in 2017. Still, we expect that key market trends such as value-based purchasing will continue. While the fate of the Center for Medicare and Medicaid Innovation (CMMI), which was created by the ACA, remains uncertain, we suspect that Medicare’s push towards value-based payment is inherently non-partisan and the movement to test different ways to pay providers based on cost and quality is here to stay. In fact, many experts predict that 2017 will be the year value-based purchasing moves from concept to reality. CMMI has implemented more than 50 demonstration programs. Some of these are becoming mandatory, including bundled payments for cardiac care and joint replacement. (At the same time, the Republican-controlled Congress may create some guardrails for CMMI, including limiting its ability to implement mandatory demonstrations.) Just around the corner, Medicare physician payment is shifting from fee-for-service (FFS) to value-based purchasing as required under MACRA . Reporting on MACRA measures begins in 2017 and will determine provider Medicare reimbursement in 2019. And the pharmaceutical industry is also engaged in value-based purchasing, increasingly pursuing outcomes-based contracts with private plans.
Where the Rubber Meets the Road
In 2017, ACCC members will need to consider how value-based payments will increasingly shift responsibility for managing cost and quality to providers, and how your cancer program is positioned to engage in a risk-based reimbursement structure. Providers should also prepare for a shift in coverage for patients, and anticipate how to respond to changes in access to care.
Now more than ever is the time for oncology care providers’ voices to be heard – join us in Washington, D.C., March 29-31 for ACCC’s annual policy meeting, Cancerscape, to understand how policy changes will impact your program and patients, engage in policy discussions with your colleagues, and help shape the future of healthcare policy in 2017 and beyond. So buckle up, check out the Cancerscape agenda, and register today.