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, 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.

“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.

“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.

A changing model

Most clinicians said the biggest change associated with the ACA will be the shift from a fee-for-service model of health care delivery to a fee-for-value model.

“We need to embrace the change from ‘pay for service’ to ‘pay for outcomes,’” Bolwell said.

However, the legislation is simply accelerating a trend already under way within the hem/onc community.

“Whether or not the Affordable Care Act was passed, the move from clinicians being paid for volume and episodic care to being paid for outcomes is occurring,” Bolwell said.

The transition is being driven by multiple entities, including CMS and commercial players, Lancaster said. When the shift takes firm hold, it will force health systems to make broader changes.

“We will have to ask ourselves this question: For each dollar I spend, how does it impact the quality of the outcomes in my patients?” Lancaster said. “Perhaps more importantly, it is going to force changes in how health systems market themselves. They will be forced to say, ‘Look at our outcomes’ rather than, ‘Look at what we did.’ It is going to be a fundamental change in the business model.”

Although Lancaster is a proponent of the change, he said he recognized the ensuing challenges.

“We won’t be able to get by with reductions in spending of 5%,” he said. “We are going to need to re-evaluate our entire care delivery model and make reductions of 20% to 30%. It will change the way oncology care is structured.”

Also, “outcomes” is a broad term that can include “everything from survival to decreases in infections, to decreases in length of hospital stay, to decreases in overall hospitalizations and complications,” Lancaster said.

Consequently, health systems eager to show positive outcomes may have a difficult time defining what those outcomes are.

Cohn and colleagues addressed this issue in a study published in Gynecologic Oncology.

The ACA established the Prospective Payment System (PPS)-Exempt Cancer Hospitals Quality Reporting program. The 11 participating hospitals are paid fee for service as opposed to a diagnosis-related group (DRG) system.

Those hospitals began reporting quality measures related to breast cancer, colon cancer and general patient safety in 2013.

In light of the reporting requirements, Cohn and colleagues wanted to evaluate whether PPS-exempt gynecologic oncology programs consistently identified quality measures related to the care of their patients.

Cohn and colleagues created 12 quality measures, then asked gynecologic oncology directors at PPS-exempt cancer hospitals to rank the outcomes in order of importance. The researchers reported “little consensus.”

“Documentation of debulking status, cancer survival, and offering minimally invasive surgery (for endometrial cancer) and intraperitoneal chemotherapy (for ovarian cancer) are important, but with widely variable responses,” Cohn and colleagues wrote. “When ranked 1-12, standard deviations are 2-3.”

Swain noted “a lot of work needs to be done” to educate the general public about the changes set to take effect on Jan. 1.

“It remains to be seen if the public will have confidence in the system to implement such a wide-scale overhaul,” Swain said.

The same holds true for clinicians, Johnson said.

“We don’t know how it is going to play out,” she said. “This makes it difficult to comment without speculation. People think everything will change with regard to reimbursement, costs, etc, but the truth is that none of us really know.”

Coordination of care

The new model may not be sustainable for individual doctors, clinicians said.

One of the cornerstones of the ACA is the move toward “caring for populations of patients across the continuum, rather than episodic care centered on the hospital,” Bolwell said.

Hence the development of accountable care organizations (ACOs), groups of physicians, hospitals and other providers who voluntarily join forces to serve Medicare patients.

“This will require hospitals and physicians to align to coordinate care and a robust electronic medical record to facilitate this,” Bolwell said. “Secondly, and most importantly, compensation will no longer be based on volume but rather value. Therefore, those who provide the best care at the lowest cost may actually have a greater profit than they experience currently. Both of these changes heavily favor physicians who practice in a large-group model, whether through hospital/system employment or horizontal integration with other like-minded specialists.”

As reimbursements go down, it will become more difficult for small practices to stay solvent, Lancaster said.

“Any time you are paid less for a product, you have to look for ways to cut costs,” Lancaster said. “Any time that happens, consolidation and merging is a natural evolution.”

The increased care coordination and communication will positively affect care and outcomes, Swain said.

“However, the turbulence that seems likely in the coming months can — in the short term — make things worse before they get better,” Swain said. “Physicians are doing their best to shield patients from this disruption, but many practices struggling under the economic and regulatory burdens may not remain viable.”

The other potential change relates to risk.

“In the current system, the insurance company bears all of the risk,” Lancaster said. “If a member of that insurance company stays healthy, the company makes $6,000 for the year, but if they get sick, the company may potentially have to pay hundreds of thousands of dollars.”

In the new system, hospitals and individual providers will assume much of the risk, Lancaster said.

“First, we will see a sharing of risk, but eventually the bulk of the risk will be held by providers,” he said. “Any given health system will be given a certain amount of money to care for the patient.”

A difficult transition

Although the debate continues about how the ACA will affect the clinical and business aspects of health care delivery, one thing is clear: It will not be a panacea for the US health care system.

For example, the outlook for the research community appears bleak.

“Unfortunately, sequestration has canceled out any positive effects the ACA may have had on research,” Moy said.

Bolwell agreed, noting concerns about cuts to NIH and NCI, as well as reductions in grant funding.

“We know so much about genomic abnormalities and have many new targets for pharmacologic interventions, but grant funding is problematic,” Bolwell said. “It is worse than it was a year ago, and that trend shows no sign of abating. There is a real chance that some high-quality research projects will not get funded. This will slow down the pace of scientific discovery to treat and cure cancer.”

Other ongoing challenges include cost, workforce shortages, and the manner in which Medicare and other payers recognize cognitive services, Swain said.

In Johnson’s view, the politics surrounding the ACA cannot be ignored.

“This has created a chasm among many people who were not even in favor of health care reform or the ACA to begin with,” she said. “But this was what was needed to get the legislation passed. There was no way they could get it passed without leaving it so nebulous.”

Yet, Johnson said the vague nature of the legislation might make it vulnerable.

“Our government has so many issues that something like this may languish,” she said. “It might not move forward at the right pace. Then nobody wins. It ends up not addressing what it was intending to address, and we are still not really grappling with the huge cost of health care.”

All things considered, though, Johnson called the ACA a positive step.

“It was necessary, particularly in a country as wealthy as ours but with so many uninsured folks,” she said. “Perhaps it didn’t go far enough.”

Lancaster also remains hopeful.

“In the long term, it will be a change for the better,” he said. “During the transition, it will be a massive undertaking for individual clinicians and health care systems, but, ultimately, patients will benefit. They will be able to select a provider by looking at the outcomes that provider has achieved.”

In Moy’s view, the success of the ACA will come down to the providers on the frontlines that will be charged with implementing the provisions of the legislation.

“Like with any transition, it will take some adjustments,” she said. “But hem/onc clinicians are some of the most dedicated professionals, and they will always place the patient first.” – by Rob Volansky

References:

Cohn DE. Gynecol Oncol. 2013;doi:10.1016/j.ygyno.2013.05.026.

Hutchins VA. J Oncol Pract. 2013;9:73-77.

Moy B. J Clin Oncol. 2011;29:3816-3824.

Rosenbaum S. Public Health Rep. 2011;126:130-135.

US Department of Labor. FAQs about the Affordable Care Act Implementation Part XV. Available at: www.dol.gov/ebsa/faqs/faq-aca15.html. Accessed on Aug. 6, 2013.

For more information:

Brian J. Bolwell, MD, FACP, can be reached at Cleveland Clinic Main Campus, Mail Code R32, 9500 Euclid Ave., Cleveland, OH 44195.

Candace Johnson, PhD, can be reached at Roswell Park Cancer Institute, Elm and Carlton streets, Buffalo, NY 14263.

Johnathan M. Lancaster, MD, PhD, can be reached at Moffitt cancer Center, 12902 Magnolia Drive, Tampa, FL 33612; email: johnathan.lancaster@moffitt.org.

Beverly Moy, MD, MPH, can be reached at Massachusetts General Hospital, 55 Fruit St., LRH-308, Boston, MA 02114; email: bmoy@partners.org.

Barry S. Rosen, MD, FACS, can be reached at Advocate Good Shepherd Hospital, 450 W. Highway 22, Barrington, IL 60010; email: barry.rosen@advocatehealth.com.

Sandra M. Swain, MD, FACP, can be reached at MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010; email: sandra.m.swain@medstar.net.

Disclosure: Bolwell, Johnson, Lancaster, Moy, Rosen and Swain report no relevant financial 
disclosures.